Multimedia educational interventions for consumers about prescribed and over‐the‐counter medications

Summary of findings for the main comparison. Summary of findings: multimedia education compared with no education or usual care

Multimedia education compared with no education or usual care for prescribed and over‐the‐counter medications
Patient or population: patients taking prescribed and over‐the‐counter medications or their carers Intervention: multimedia education Comparison: no education or usual care
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	no education or usual care	multimedia education
Knowledge (< 4 weeks) Mean number of correct responses (higher score indicates higher knowledge) Follow‐up: 0 to 3 weeks		The mean knowledge (< 4 weeks) in the intervention groups was 1.04 higher (0.49 to 1.58 higher)		817 (6 studies)	++OO low^a,b	Standardised score used as one study (Deitz 2011) did not provide a denominator and therefore could not be converted to the same scale as the other studies. A standard deviation of 1.04 represents a large difference between groups. 1 further study of 167 patients measured the number whose knowledge score improved and found that this was 458 versus 202 per 1000 in the intervention and control groups respectively (RR 2.26, 95% CI 1.39 to 3.67). The quality of the evidence was low^a,c. 1 study with 8 patients measured mean knowledge (%) at 4 weeks or more and found it was 22.5 higher (0.42 lower to 45.42 higher) in the intervention group. The quality of the evidence was very low^a,c,d.
Skill acquisition Mean inhaler technique score (%), higher score indicates better technique. Scale from: 0 to 100. Follow‐up: 0 to 9 months	The mean skill acquisition in the control groups was 71.22%^e	The mean skill acquisition in the intervention groups was 18.32 higher (11.92 to 24.73 higher)		94 (2 studies)	+++O moderate^a
Compliance with medication (different measures used by the studies: patient self‐report of compliance and prescription refill data). Follow‐up: 3 to 39 weeks	Low risk population^f		RR 1.02 (0.96 to 1.08)	4552 (2 studies)	+++O moderate^a
	443 per 1000	452 per 1000 (425 to 478)
	Medium risk population^f
	704 per 1000	718 per 1000 (676 to 760)
	High risk population^f
	965 per 1000	984 per 1000 (926 to 1000)
Health outcomes: Drug misuse and dependence CAGE screening tool. Scale from 0 to 4. Higher score indicates greater probability of drug misuse or dependence	The mean CAGE score in the control group was 0.86	The mean CAGE score in the intervention group was 0.38 lower (0.60 lower to 0.15 lower)		329 (1 study)	++OO low^a,c	1 further study with 43 participants measure pain on a scale of 0 (no pain) to 10 (worst possible pain) and found that pain in the intervention group was 0.5 lower (1.44 lower to 0.44 higher). However, the quality of evidence was very low^c,g.
Medication side effects ‐ not measured	See comment	See comment	Not estimable	‐	See comment	One study measured medication side effects but did not report results in a form that could be extracted for meta‐analysis. The authors reported no statistically‐significant difference in the incidence of side effects between the two groups.
Quality of life ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured quality of life.
Self‐efficacy Self‐efficacy for medication adherence (higher score indicates greater self‐efficacy, scale not reported)	The mean self‐efficacy in the control group was 56.88	The mean self‐efficacy in the intervention group was 1.94 higher (0.56 lower to 4.44 higher)		343 (1 study)	++OO low^a,c	1 further study with 99 patients measured self‐efficacy for avoiding drug interactions (scale of 1 to 5) and found that mean self‐efficacy in the intervention groups was 1.38 higher (0.9 to 1.86 higher). The quality of the evidence was low^a,c.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk Ratio; SMD: Standardised Mean Difference
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
a. All of the studies had unclear risk of bias for allocation concealment, blinding of outcome assessors or both. b. Considerable statistical heterogeneity (I² = 89%). However, all but one of the studies (Deitz 2011) favoured the multimedia group. Heterogeneity may be due to variability in the education provided to the control group as part of usual care. c. Results are from only one study. d. Wide 95% confidence interval including both no effect and substantial effect in the direction of the intervention group. e. Control groups results measured at the same time point as was used in the meta‐analysis were used to calculate mean scores across the included studies. f. Three assumed baseline risks were provided based on the control group risks in the included studies (low and high risk) and the median risk across the two studies (medium). g. The study was at high risk of bias due to lack of allocation concealment.

Summary of findings 2. Summary of findings: multimedia education compared with written education

Multimedia education compared with written education for prescribed and over‐the‐counter medications
Patient or population: patients taking prescribed and over‐the‐counter medications or their carers Intervention: multimedia education Comparison: written education
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	written education	multimedia education
Knowledge (number whose knowledge score improved) Follow‐up: one day	570 per 1000^a	458 per 1000 (336 to 621)	RR 0.80 (0.59 to 1.09)	162 (1 study)	+OOO very low^b,c	More patients had perfect scores at baseline in the multimedia group (241 versus 165 per 1000). Improvement could not be detected in these patients which may have biased results in favour of written education.
Number who improved on skill (global inhaler technique rating) Follow‐up: mean one hour	Low risk population^d		RR 2.14 (1.33 to 3.44)	164 (2 studies)	+++O moderate^e	1 further study with 20 participants reported that mean inhaler technique score (%) was 31 higher (10.15 to 51.85 higher) in the intervention group. The quality of the evidence was low^b,c.
	180 per 1000	385 per 1000 (239 to 619)
	Medium risk population^d
	222 per 1000	475 per 1000 (295 to 764)
	High risk population^d
	260 per 1000	556 per 1000 (346 to 894)
Compliance with medication	See comment	See comment	Not estimable	‐	See comment	No studies measured compliance with medication.
Health outcomes ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured health outcomes.
Medication side effects ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured medication side effects.
Quality of life ‐ not measured	See comment	See comment		‐	See comment	No studies measured quality of life.
Self‐efficacy ‐ not measured	See comment	See comment		‐	See comment	No studies measured self‐efficacy.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk Ratio
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
a. The assumed risk was calculated from the mean baseline risk in the single study included in the meta‐analysis. b. The study had unclear risk of bias for allocation concealment and blinding of outcome assessors. c. Results are from only one study. d. Three assumed baseline risks were provided based on the control group risks in the included studies (low and high risk) and the median risk across the two studies (medium). e. Studies had unclear risk of bias for allocation concealment.

Summary of findings 3. Summary of findings: multimedia education compared with education by a health professional

Multimedia education compared with education by a health professional for prescribed and over‐the‐counter medications
Patient or population: patients taking prescribed and over‐the‐counter medications or their carers Intervention: multimedia education Comparison: education by a health professional
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	education by a health professional	multimedia education
Knowledge Mean number of correct responses (%). Scale from: 0 to 100. Follow‐up: mean 1 day	The mean knowledge in the control groups was 88.9 %^a	The mean knowledge in the intervention groups was 2.2 lower (8.83 lower to 4.43 higher)		22 (1 study)	+OOO very low^b,c
Skill acquisition (< 4 weeks) Mean inhaler technique score (%), higher score indicates better technique. Scale from: 0 to 100. Follow‐up: 0 to 2 weeks	The mean skill acquisition (< 4 weeks) in the control groups was 76.7%^a	The mean skill acquisition (< 4 weeks) in the intervention groups was 1.01 lower (15.75 lower to 13.72 higher)		130 (3 studies)	+OOO very low^d,e,f	Two studies with 130 patients reported skill acquisition at 4 weeks of more and found that mean inhaler technique score (%) was 4.29 lower (17.23 lower to 8.65 higher) in the intervention group. The quality of the evidence was low^d,e.
Compliance with medication ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured compliance with medication.
Health outcomes Bronchial obstruction (FEV), higher score indicates less bronchial obstruction. Theoretical maximum scores were 2.72 for the multimedia and 3.14 for the control group. Follow‐up: 15 days	The mean FEV (at 15 days) in the control group was 2.09^a	The mean FEV (at 15 days) in the intervention group was 0.29 higher (0.26 lower to 0.84 higher)		28 (1 study)	+OOO very low^c,e,g
Medication side effects ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured medication side effects.
Quality of life ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured quality of life.
Self‐efficacy ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured self‐efficacy.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk Ratio; MD: Mean Difference; FEV: Forced Expiratory Volume
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
a. Control groups results measured at the same time point as was used in the meta‐analysis were used to calculate mean scores across the included studies. b. The study was at high risk of bias due to lack of allocation concealment. c. Results were based on one study with a small sample size and wide 95% confidence interval. d. All of the studies had unclear risk of bias for blinding of outcome assessors. All of the studies except Lirsac 1991 also had unclear risk of bias for allocation concealment. e. Wide 95% confidence interval including both no effect and substantial effect. f. Substantial statistical heterogeneity (I² = 68%) which may be due to differences in the education provided to the control group. g. The study had unclear risk of bias for blinding of outcome assessors.

Summary of findings 4. Summary of findings: multimedia education compared with written education and education by a health professional

Multimedia education compared with written education and education by a health professional for prescribed and over‐the‐counter medications
Patient or population: patients taking prescribed and over‐the‐counter medications or their carers Intervention: multimedia education Comparison: written education and education by a health professional
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	written education and education by a health professional	multimedia education
Knowledge ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured knowledge.
Compliance with medication ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured compliance with medication.
Number who improved on skill (rating of inhaler technique) Follow‐up: mean 1 day	429 per 1000^a	502 per 1000 (300 to 832)	RR 1.17 (0.7 to 1.94)	69 (1 study)	+OOO very low^b,c
Health outcomes ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured health outcomes.
Medication side effects ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured medication side effects.
Quality of life ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured quality of life.
Self‐efficacy ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured self‐efficacy.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk Ratio
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
a. The assumed risk was calculated from the mean baseline risk in the single study included in the meta‐analysis. b. The study had unclear risk of bias for allocation concealment. c. Results were based on a single study with a relatively small sample size and wide confidence interval.

Summary of findings 5. Summary of findings: multimedia education compared with control multimedia

Multimedia education compared with control multimedia for prescribed and over‐the‐counter medications
Patient or population: patients taking prescribed and over‐the‐counter medications or their carers Intervention: multimedia education Comparison: control multimedia
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	control multimedia	multimedia education
Knowledge Mean number of correct responses (%). Scale from: 0 to 100. Follow‐up: 3 to 6 months	The mean knowledge in the control groups was 61%^a	The mean knowledge in the intervention groups was 2.78 higher (1.48 lower to 7.05 higher)		568 (2 studies)	+++O moderate^b
Skill acquisition Inhaler technique (scored 0 to 100 and reported as change in score from baseline) Follow‐up: 1 month	The mean change in inhaler technique score in the control group was 1.62 out of 100^a	The mean change in inhaler technique score in the intervention group was 13.3 higher (8.98 to 17.62 higher)		116 (1 study)	++OO low^b,c	Data from the last time point at which the outcome was measured included in the 'Summary of findings' table.
Compliance with medication. Mean score of the Chronic Disease Compliance Instrument (CDCI), higher score indicates better compliance. Scale from: 18 to 90. Follow‐up: 3 months	The mean compliance with medication in the control groups was 78.4 out of 90^a	The mean compliance with medication in the intervention groups was 2.6 higher (0.78 to 4.42 higher)		303 (1 study)	++OO low^c,e
Health outcomes Peak expiratory flow readings (higher readings indicate better peak flow) Follow‐up: 1 day	The mean peak flow in the control group was 382^d	The mean peak flow in the intervention group was 21 higher (5.28 to 37.20 higher)		116 (1 study)	++OO low^b,c
Medication side effects ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured medication side effects
Quality of life (QOL). Outcome was measured on different scales in different studies (higher score indicates better QOL) Follow‐up: mean 3 months		The mean quality of life in the intervention groups was 0.2 higher (0.04 lower to 0.44 higher)		269 (1 study)	+++O moderate^c	A standard deviation of 0.2 represents a small difference between groups. SMD 0.2 (‐0.04 to 0.44)
Self‐efficacy. Self efficacy score (higher score indicates greater self‐efficacy). Scale from: 27 to 189. Follow‐up: mean 3 months	The mean self‐efficacy in the control groups was 158.8 out of 189^a	The mean self‐efficacy in the intervention groups was 5.3 higher (0 to 10.6 higher)		303 (1 study)	+++O moderate^c
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk Ratio; SMD: Standardised Mean Difference
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
a. Control groups results measured at the same time point as was used in the meta‐analysis were used to calculate mean scores across the included studies. b. One or more of the studies had unclear risk of bias for allocation concealment. c. Results are based on only one study. d. The assumed risk was calculated from the mean baseline risk in the single study included in the meta‐analysis. e. Baseline compliance levels were higher in the intervention group.

Summary of findings 6. Summary of findings: multimedia education and a co‐intervention compared with co‐intervention alone

Multimedia education and a co‐intervention compared with the co‐intervention alone for prescribed and over‐the‐counter medications
Patient or population: patients taking prescribed and over‐the‐counter medications or their carers Intervention: multimedia education and a co‐intervention Comparison: co‐intervention alone
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	co‐intervention alone	multimedia education and a co‐intervention
Knowledge (< 4 weeks) Mean number of correct responses (%). Scale from: 0 to 100. Follow‐up: 2 to 14 days	The mean knowledge (< 4 weeks) in the control groups was 68.76%^a	The mean knowledge (< 4 weeks) in the intervention groups was 24.59 higher (22.34 to 26.83 higher)		381 (2 studies)	+++O moderate^b	1 study with 60 patients measured mean knowledge (%) at 4 weeks or more and found it was 23.3 higher (12.82 to 33.58 higher) in the intervention group. The quality of the evidence was low^b,c.
Skill acquisition Mean inhaler technique score (%), higher score indicates better technique. Scale from: 0 to 100. Follow‐up: mean 2 weeks	The mean skill acquisition in the control groups was 59.1%^a	The mean skill acquisition in the intervention groups was 3.4 higher (8.3 lower to 15.1 higher)		87 (1 study)	+OOO very low^b,c,d
Non‐compliance with medications score Mean non‐compliance score (lower scores indicate better compliance). Scale from: 0 to 160. Follow‐up: 2 to 6 days	The mean non‐compliance score in the control groups was 40.45 out of 160^a	The mean non‐compliance score in the intervention groups was 32.15 lower (51.13 to 13.17 lower)		320 (1 study)	++OO low^b,c	1 further study with 77 patients measured the number who completed their course of medications and found that this was 659 versus 639 per 1000 in the intervention and control groups respectively (RR 0.97, 95% CI 0.7 to 1.35). The quality of the evidence was low^c,d.
Health outcome (Number who had a medical complication of pelvic inflammatory disease) Follow‐up: two weeks	317 per 1000^e	361 per 1000 (193 to 675)	RR 1.14 (0.61 to 2.13)	77 (1 study)	++OO low^c,d
Medication side effects Mean adverse self‐medication behaviour score (lower scores indicate safer self‐medication behaviour). Scale from: 0 to 40. Follow‐up: mean 4 weeks	The mean medication side effects in the control groups was 21 out of 40^a	The mean medication side effects in the intervention groups was 5 lower (10.06 lower to 0.06 higher)		60 (1 study)	+OOO very low^b,c,f	Data from the last time point at which the outcome was measured included in the 'Summary of findings' table.
Quality of life ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured quality of life
Self‐efficacy Self‐efficacy rating scale (higher score indicates greater self‐efficacy). Scale from: 1 to 5. Follow‐up: mean 4 weeks	The mean self‐efficacy in the control groups was 3 on 1‐5 rating scale^a	The mean self‐efficacy in the intervention groups was 0.9 higher (0.52 to 1.28 higher)		60 (1 study)	++OO low^b,c	Data from the last time point at which the outcome was measured included in the 'Summary of findings' table.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk Ratio
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
a. Control groups results measured at the same time point as was used in the meta‐analysis were used to calculate mean scores across the included studies. b. The studies had unclear risk of bias for allocation concealment. c. Results were based on only one study. d. Wide 95% confidence interval including both no effect and substantial effect in the direction of the multimedia group. e. The assumed risk was calculated from the mean baseline risk in the single study included in the meta‐analysis. f. Outcome measures patient behaviours that are likely to cause medication adverse effects rather than measuring medication adverse effects directly.

Background

Patient education about medications

Health consumers increasingly want access to accurate, evidence‐based information about their health condition and its treatment. There is evidence, however, that current methods for delivering this information are not meeting their needs. Studies have shown a mismatch between health professionals' and health consumers' views about the amount and type of information patients should receive about their medications (Berry 1997; Nair 2002). These groups also appear to have different priorities relating to the purpose of medication information (Grime 2007). Health consumers generally want more information than is provided to facilitate informed decision making, presented in a way that is easy to understand; whereas health professionals focus upon the need to improve medication compliance, save consultation time and establish medico‐legal evidence of informed consent.

Formats for delivering educational materials

For information to be useful for health consumers it needs to be presented in a format that they can understand. Currently, patient information about medications is presented predominantly via spoken communication between the health provider and consumer, sometimes supplemented with written materials. Studies have shown that patients find it difficult to retain information told to them by their doctors, with 40 to 80% of information forgotten immediately (Ley 1982). The amount of information retained is inversely proportional to the amount of information presented, and almost half of the information that is retained is remembered incorrectly (Kessels 2003). Written information that is provided to reinforce verbal communication has been shown to produce variable results. A Cochrane review of written information for consumers about medications found that while some studies showed that patients given written information had improved knowledge about their medications, overall the results were mixed (Nicolson 2009). Moreover the quality of written materials about medications may vary, particularly with respect to their content, structure and usability (Buchbinder 2001; Clerehan 2005; Clerehan 2009).

Potential value of multimedia education programs

Multimedia education programs which provide information using more than one format offer many potential advantages over traditional forms of information delivery. The combination of audio with graphic presentation of information, or the use of animation or video may overcome barriers that poor literacy creates for some consumers (Liao 1996; Wofford 2001). Multiple studies have shown that learning is improved when students are presented with information in an audiovisual, rather than visual only, format (Kalyuga 2000; Mayer 1998; Moreno 1999; Tindall‐Ford 1997). As opposed to spoken communication from a health professional, multimedia education programs can be viewed at a pace that suits the consumer, with information repeated as required. They can be provided using different technologies, many of which are portable or can be accessed over the Internet. This allows consumers and their families to access the information at a time and place that is convenient for them, and the information to be widely disseminated at little cost. The anonymity provided by the programs may allow patients to access information that they may be uncomfortable requesting from their doctor. One of the advantages of multimedia programs over written materials is that they often allow information to be tailored, or personalised, to individual patients and their needs. Tailored information is more likely to be used and viewed as relevant compared with generic information. There is also some evidence that it may be more effective at modifying health‐related behaviours (Lustria 2009).

Multimedia programs vary in their interactivity, which is defined as the degree of user control and program responsiveness. User control is the ability of the user to alter the form and content of a program, select topics or services and the order in which they are presented, and respond to information presented. Responsiveness is the degree to which a program is able to take into account and respond to the actions of the user. Interactivity increases user engagement, active information processing and satisfaction, and increases the effectiveness of educational materials (Street 1997).

Like any other information format, multimedia education programs may also vary in content accuracy. Additional quality concerns include the ease with which the written, spoken or graphical information is understood, and the usability of the program. The way the program is delivered may also result in the exclusion of certain sections of the population who do not have access to the technology or the technical knowledge required to use it. This may be a particular problem for people from low socioeconomic backgrounds and/or the elderly (Bozionelos 2004; Wright 2009).

The impact of patient education about medications

Tones 1994 defined health education as any intentional activity which is designed to achieve health‐ or illness‐related learning. Information about medications which aims to produce changes in areas including knowledge, beliefs, skills and behaviours would meet this definition for health education. The aims and therefore the relevant outcomes of health education vary. The most direct effect of education would be to increase knowledge and skill levels. Health consumers who are prescribed medications are expected to perform certain self‐management tasks. These include making an informed decision about taking the medication, self‐administering the medication at the right dose and time, monitoring their response to treatment, recognising side effects of the medication and alerting health professionals if they are not responding or develop side effects. These self‐management tasks are particularly important for those suffering chronic conditions. Many health consumers may take multiple medications which makes self‐management more complex and increases the risk of adverse events (Gray 2009). To perform these tasks successfully, health consumers require detailed information about their medications.

Increased knowledge about medications may lead to changes in health‐related behaviour and improved health outcomes. However, a recent overview of systematic reviews evaluating the effects of consumer‐oriented interventions on medicines use suggests that patient education limited to information provision alone is insufficient to effect change (Ryan 2011). Guidelines for the management of asthma recommend the use of additional strategies including patient self‐monitoring, regular medical review and the used of a written action plan, which, in combination with patient education, have been shown to improve health outcomes (Gibson 2002). Ryan's overview supports this approach, finding that interventions that included self‐monitoring and self‐management, and possibly the combination of education with self‐management, show promise in improving adherence and medicine use (Ryan 2011). There may also be more direct effects of education on patients’ emotions, beliefs and attitudes as well as health‐related behaviour, which have not been evaluated in these reviews.

Much of the literature related to patient education about medication and behaviour change has focused upon medication compliance or adherence, which is defined as the degree to which a person’s behaviour coincides with medical advice. This assumes that the patient has a passive role in accepting medical direction (Bajramovic 2004). Studies of educational interventions about medications have shown mixed effects on compliance, with some interventions successfully increasing knowledge without a resulting increase in compliance rate (Brus 1998; Cote 1997). A Cochrane review found that interventions that were effective for improving patient compliance with long‐term treatments were typically complex and multi‐faceted (Haynes 2008). The failure of educational interventions to improve compliance rates may be due to the frequency of intentional non‐compliance. This is where patients deliberately choose, for reasons such as side effects or perceived lack of effectiveness, not to take their medication as prescribed (Lowe 2000). These decisions are often not reported back to the treating doctor.

More recently, the emphasis in medication prescription has shifted from 'compliance' to 'concordance'. Concordance entails a partnership, with two‐way communication between the patient and the health professional. The patient is encouraged to share their preferences and beliefs, is fully informed about the benefits and risks of treatment, and participates as a partner with the health professional in reaching agreement about treatment (Stevenson 2004). This collaborative approach to prescribing medications, whereby the patient is involved in the discussion and decision‐making process, has been shown to improve patients’ knowledge and initial beliefs about the medication, medication use, and satisfaction with both medication and care (Bultman 2000). Patient education about treatment is a vital component of the concordance model. However, concordance is difficult to measure, and it has not been widely adopted as an outcome measure for evaluating the effectiveness of educational interventions. Patient‐reported outcomes measuring health consumers' perception of components which make up the concordance model are more readily measurable. These may include their attitudes and beliefs about medications, satisfaction with the education and care they received, participation in decision making, and confidence in their ability to perform health‐related tasks (self‐efficacy).

As well as examining the benefits of patient education, it is also important to ensure that it is not causing any harm. There is evidence that medication compliance is not decreased by informing patients of a medication's potential adverse events (Haynes 2008). However, particular studies have raised concern that informing patients of all potential risks of a medication may increase anxiety and the incidence of medication side effects by suggestion, overload them with too much information from which they will be unable to weigh potential risks against benefits, and lead to their missing out on beneficial treatments (Fraenkel 2002; Pullar 1990).

Relationship to other reviews

This review covers multimedia education about medications for any condition, and therefore is likely to overlap with other existing Cochrane and non‐Cochrane reviews. Two reviews, performed in 2005 and 2008, examined randomised controlled trials of multimedia patient educational interventions (Jeste 2008; Wofford 2005). The reviews used different definitions for multimedia: Wofford 2005 defined it as using graphics (animation or video) and/or audio with or without the use of supporting text, while Jeste 2008 defined it as utilising both an auditory‐verbal channel and a visual‐pictorial channel. Wofford 2005 limited interventions to those that utilised desktop computers for delivery, therefore excluding interventions delivered as videotapes or using portable devices. Jeste 2008 excluded interventions aimed at carers and studies that did not report objective measures of knowledge. Both reviews excluded studies that were not published in English and had study participants less than 18 years of age. Our review is more comprehensive in that we did not restrict inclusion to studies published in English, nor by age or category of health consumer, and we considered a wide range of outcomes, including interventions targeted to carers and outcomes for carers. Our definition of multimedia is also broader. Although both reviews focused on educational interventions they also included decision aids and interventions providing counselling, cognitive behavioural therapy, emotional support and case management. They also included interventions that contained multiple components, where the effect of multimedia education on outcomes could not be separated from the effect of other components of the intervention.

The Cochrane review by Murray et al (Murray 2005) deals with Interactive Health Communication Applications (IHCAs) for people with chronic diseases. These are defined as computer‐based information packages for patients that combine health information with at least one other intervention such as decision support, behaviour change support or peer support. Complex programs involving multiple interventions in combination with health information were excluded from our review unless the effect of the multimedia educational intervention on measured outcomes was clearly separated from the impact of the other interventions. Our review will not be limited to people with chronic conditions nor by the type of technology used to deliver the program. IHCAs are, by their definition, interactive, but do not necessarily have a multimedia component. Non‐interactive interventions such as video were therefore not considered in Murray's review.

A number of reviews examine the effectiveness of education, and other types of interventions, at improving medication adherence (Haynes 2008; M'Imunya 2012; Rueda 2006). The M'Imunya and Rueda reviews are disease specific, in that they deal with any type of intervention that aims to improve adherence to treatments for tuberculosis and HIV respectively. The Haynes review is much broader, in that it deals with any type of intervention intended to improve adherence to prescription medications used to treat any condition. All of these reviews focus on adherence and clinical outcomes. However, it is likely that they will contain some studies which overlap with our review. An overview of systematic reviews examines consumer‐oriented interventions for evidence‐based prescribing and medicines use (Ryan 2011). This overview includes a broad range of interventions and outcomes and may contain studies which overlap with our review.

A number of Cochrane reviews examine self‐management education, particularly for the management of chronic diseases (Effing 2007; Powell 2002; Shaw 2010). Self‐management education teaches skills that allow patients to identify their problems, and provides them with techniques to help them make decisions, take appropriate actions and alter those actions as they encounter changes in circumstance or disease. The development of an action plan is a central feature of this process (Bodenheimer 2002). Education is a key component of self‐management programs. Our review will focus on purely educational interventions where medication‐specific information and technical skills are transferred to a patient. Our review will include studies in which the purpose of this information transfer is to improve self‐management, but will exclude more complex self‐management education programs unless the effect of the multimedia educational component can be separated from the effect of the other components of the program.

Why it is important to do this review

Despite the potential benefits of multimedia compared with traditional methods of patient education delivery, there is concern that the application of these programs may precede evidence of their effectiveness (Robinson 1998). The development and production of multimedia programs is expensive, especially when this is compared to the limited cost involved in producing information leaflets. Although there have been a number of Cochrane reviews in the area of patient education, this will be the only review that looks specifically at the effects of multimedia presentation of information related to medication on knowledge, skills, and health outcomes.

Objectives

To assess the effects of multimedia patient education interventions about prescribed and over‐the‐counter medications in people of all ages, including children and carers.

Methods

Criteria for considering studies for this review

Types of studies

We included randomised controlled trials (RCTs) and quasi‐RCTs (in which methods of allocating participants to treatment are not strictly random, e.g. using alternation, date of birth, or some similar method of allocation). Some studies professing to be RCTs are actually quasi‐RCTs. However, this can only be determined during a risk of bias assessment and only in studies that adequately report their methods for randomisation. We therefore decided to include all RCTs and quasi‐RCTs and then deal with randomisation issues in the Risk of bias in included studies and in sensitivity analysis. Studies that randomised individuals or cluster‐randomised trials that randomised by groups, for example by medical practice, were eligible for inclusion.

Types of participants

Participants included people of all ages who had been prescribed (or directly administered by a health professional) a particular medication or medication regimen, or who had obtained an over‐the‐counter medication. We included children and carers if the intervention had been targeted for their use. Participants also included people who were provided with education about a particular medication, medication regimen or over‐the‐counter medication but who had not been prescribed or obtained the medication.

We excluded studies relating to unlicensed medications and complementary medicines, including vitamins and nutritional supplements.

Types of interventions

We included studies of multimedia‐based patient education about prescribed or over‐the‐counter medications.

Intervention format

Multimedia was defined as the delivery of information using a combination of formats. Formats were divided into:

text, still graphics or photographs
animation and video
audio

We included interventions that delivered information using a combination of at least two different formats. However, we excluded interventions if they contained only text with still graphics or photographs, e.g. printed pamphlets with pictures or Internet pages with text and still pictures.

We included multimedia interventions which were interactive or tailored. All mechanisms for delivering multimedia programs (such as web‐based, DVD and CD‐ROM) were included in the review. We included studies that evaluated multimedia interventions directed at participants both before they had started their medication and once they were already taking it.

Intervention content

For the study to be included in the review, the educational intervention must have included information or education about a particular medication or group of medications as its primary focus. We excluded interventions that did not contain an education component (e.g. electronic history taking).

Complex programs that included a multimedia education program as part of a number of interventions were only included if the impact of the multimedia intervention on measured outcomes could be clearly separated from the effect of the other interventions. Decision aids, which are primarily designed to assist consumers in choosing between treatment options, were not included. The intervention must have been designed to inform or educate health consumers or their carers. We excluded interventions that were aimed at educating health professionals.

Comparison interventions

The main comparison groups included:

no education;
standard or usual care i.e. where no standardised educational intervention is provided as part of the trial but participants received non‐standardised education from health professionals involved in their care;
other forms of education (not using the multimedia format)
a control multimedia education program that provides generic information, or information not pertaining to the medication or treatment being considered in the study.

The content of the comparison interventions was assessed in the same way as for the multimedia educational interventions.

Types of outcome measures

The type of outcomes reported was not used to determine study eligibility for inclusion. Both binary and continuous outcomes were selected as appropriate. We extracted data, when available, for all of the following outcomes for each of the trials, extracting data at all time points measured.

Primary outcomes

The primary outcomes were:

Patient or carer knowledge about the medication. Increased knowledge about a medication was considered the most direct effect of an educational intervention.
Any measure of skill acquisition related to the medication (e.g. ability to administer injectable medications appropriately).

Secondary outcomes

Secondary outcomes included:

Health‐related behaviour, including medication compliance/adherence or concordance.
Health outcomes, including disease‐related outcomes and safety data including adverse events related to the medication.
Patient‐ or carer‐reported outcomes: these were varied and included quality of life, self‐efficacy, emotions (including anxiety caused by the educational intervention), beliefs and attitudes about the medication, satisfaction with the care and education received, and the user's perception of the quality and usability of the educational intervention. Outcomes relating to self‐management itself (such as perception of ability to self‐manage) were included here, while measures of ability to perform specific self‐management tasks (such as safely self‐administer medication) were included under skill acquisition in the primary outcomes.
Participant usage of the intervention.
Cost, including the cost of health care, the cost‐effectiveness of the educational intervention, and resource utilisation such as the number of hospital admissions and medical reviews.

Search methods for identification of studies

Electronic searches

We searched the following electronic databases and sources to identify studies:

Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) to June 2011;
MEDLINE (Ovid) 1950 to June 2011;
EMBASE (Ovid) 1974 to June 2011;
CINAHL (EBSCOhost) 1982 to June 2011;
PsycINFO (Ovid) 1967 to June 2011;
ERIC (Educational Resources Information Centre) 1966 to June 2011;
ProQuest Dissertation & Theses Database to June 2011.

We present the search strategies in Appendix 1 to Appendix 7. There were no language restrictions.

Searching other resources

We systematically searched the reference lists of reviews that potentially overlapped with our review, reviews identified by our search strategy and the studies retrieved in full text, to identify potentially relevant studies. We also checked the personal records of the review authors to identify any further studies for inclusion.

Data collection and analysis

Selection of studies

Two review authors (SC, RJ) independently screened the titles and abstracts of identified studies for possible inclusion, and removed duplicate records of the same report. The full text of all potentially‐relevant studies were retrieved and assessed for inclusion. If studies had insufficient information on which to base a decision, we contacted the study authors to obtain further information. Disagreements regarding inclusion were resolved by discussion and consensus, or by consulting a third author. Relevant studies that we excluded are listed in the Characteristics of excluded studies table with the primary reason for exclusion given.

Data extraction and management

Two review authors (SC, RJ) independently extracted data from all included studies using a form derived from the data extraction template of the Cochrane Consumers and Communication Review Group. Disagreements were resolved by discussion or through a third party. Extracted data included details about the participants, the intervention, the outcomes assessed and the study results. Extracted data were summarised in the Characteristics of included studies tables.

Data extracted about participants included general demographics information and where available, information about: their literacy (as defined or reported by the study authors); educational level; the medical condition being treated; their co‐morbidities; and other medications they were receiving.

Information extracted about the intervention included the format or media used, when and how it was delivered, whether it reached its intended audience, and details regarding the type and degree of interactivity or tailoring.

Based upon systemic functional linguistics, two of the authors (RC and RB) have previously developed a linguistic framework, the Evaluative Linguistic Framework (ELF), for evaluating the quality of medication leaflets intended for patients (Clerehan 2005; Clerehan 2009). From this work, which included consumer input about what information needs to be included (Hirsh 2009), we found that medication leaflets have an identifiable generic structure that may include up to ten 'moves' or identifiable sections.

These include:

Background of the drug;
Summary of use of drug;
Dosage instructions;
Outline of benefits of drug;
Account of side‐effects;
Information regarding monitoring required e.g. regular blood tests
Constraints on patient behavior (including information about drug interactions);
Contraindications to use;
Storage instructions; and
Clinical contact availability

We contacted study authors to request access to the multimedia intervention. Where this was not made available, our evaluations were based on descriptions of the intervention from the studies. The specific content of the multimedia educational interventions was extracted and assessed according to the ten ELF content areas.

In addition, we systematically evaluated and report the quality of the multimedia intervention according to the ELF (Clerehan 2009) (Table 1). The ELF was specifically developed for written patient information and was adapted for assessment of the quality of multimedia patient education interventions. It considers the generic or overall structure of the intervention, its rhetorical elements (function of each section, such as to define, instruct or inform the reader), nature of the relationship between the developer and reader (such as medical expert to layperson, etc), metadiscourse (description of the purpose or structure of the text), headings, the technicality of the medical terminology, density of the content words (or 'lexical density') and its factual content. We documented whether literacy, format, readability and usability issues were considered. In addition we determined whether health consumers were involved in its development.

Table 1. Framework for evaluating healthcare text based upon systemic functional linguistics

Item	Description	Assessment
Overall organisational or generic structure of the text	Series of stages or moves in a text (e.g. background on drug, dosage instructions, account of side effects)	What identifiable sections of text (moves) are present? Are all essential moves included? What is the sequence of moves and is this appropriate?
Rhetorical elements	The function of each move in relation to the reader (e.g. to define, instruct, inform)	What are the rhetorical functions of each move in relation to the reader? Are these clearly defined and appropriate? Is there clear guidance about what to do with the presented information? Are instructions clear about what action needs to be taken?
Relationship between writer and reader	Nature of the relationship between the writer and reader (e.g. medical expert to layperson; doctor to his/her patient)	Is it clear who the writer and intended audience is? Is the relationship between writer and reader clear and consistent? Is the person who is expected to take responsibility for any actions clear? Is the importance and/or urgency of the action made clear? How positive (encouraging, reassuring) is the tone?
Meta discourse	Description of the purpose/structure of the text	Is there a clear description of the purpose of the text?
Headings	Signposts in the text for the reader	Are headings present? If present, are they appropriate?
Technicality of vocabulary	The technicality of the medical terminology/other vocabulary that is used	How technical is the vocabulary that is used in the text? Is this appropriate?
Lexical density	Density of the content words in the text	What is the average content density of the text (percentage of content‐bearing words)? Is this appropriate?
Factual content of text	Facts included in the text	Is the factual information correct and up‐to‐date? Is the source of information provided? Is the quality and strength of the evidence discussed?
Format	Visual aspects such as layout, font size, style, use of visual material, etc.	What is the length, layout, font size and visual aspect of the document?

If a trial included multiple measures of a particular outcome (e.g. knowledge), we extracted only one of these measures to prevent double counting. If the study identified one of the measures as the primary outcome, or specified it in its sample size calculation, then we extracted these data. Otherwise the decision as to which measure to extract was made by consensus opinion of the authors, based on the clinical importance of the outcome, whether the measure had been validated and found to be reliable, and its similarity to those reported in other studies. Authors involved in this decision were blinded to the results for each of the outcomes.

Where studies reported outcomes at more than one time point, we examined and reported data at all time points to determine if the effects of the intervention, particularly on acquisition of knowledge and skills, persisted or changed over time. For the meta‐analysis we decided to divide time points into those that were short‐term (< 4 weeks) and long‐term (≥ 4 weeks) and if there were multiple time points within these categories, we extracted data from the last time point measured. This division of time points was a post‐hoc decision based on the range of time points reported by the included studies.

Assessment of risk of bias in included studies

We assessed and reported the risk of bias of included studies in accordance with the Cochrane Handbook (Higgins 2011a), which recommends the explicit reporting of the following individual elements for RCTs: sequence generation; allocation concealment; blinding, incomplete outcome data; selective outcome reporting; and other sources of bias. For each of these domains, we described the methods used in each study, and made a judgment about the risk of bias using the guidelines in Higgins 2011a, with each domain judged as having low, high or unclear risk of bias. Blinding was assessed for both participants and outcome assessors. Studies were judged to be at low risk of bias if both the participants and assessors were adequately blinded; if the outcomes measured were objective and unable to be influenced by lack of blinding or if the assessment occurred immediately following the intervention, minimising the potential for the lack of blinding of participants to influence outcomes. We also examined the method of intervention delivery to determine if it had the potential to cause selection bias; for example, inadvertently selecting participants from higher socioeconomic backgrounds or with higher levels of educational attainment by only including participants who have access to certain technologies. We contacted study authors for additional information about the included studies, or for clarification of the study methods as required. We incorporated the results of the 'Risk of bias' assessment into the review through systematic narrative description and commentary about each of the elements, leading to an overall assessment of the risk of bias of included studies, a judgement about the internal validity of the review’s results and a GRADE assessment of the quality of evidence for each outcome (Schünemann 2008b).

Measures of treatment effect

We analysed separately studies that compared the multimedia intervention to no intervention (including usual care), to other forms of education (written information, education by a health professional or both) and to other multimedia interventions, as well as those that compared multimedia in combination with a co‐intervention to the co‐intervention alone. Effects were expressed as mean differences (MD) and 95% confidence intervals (CI) for continuous outcomes and risk ratios (RRs) and 95% CI for dichotomous outcomes. For continuous outcomes, if individual studies used different scales to measure the same outcome (and results could not be converted into the same scale) then we used standardised mean differences (SMD).

Unit of analysis issues

We intended that potential unit of analysis errors, caused by cluster randomised trials failing to appropriately account for correlation of observations within clusters, would be corrected by incorporating an approximate analysis of the trial using methods recommended by the Cochrane Collaboration (Higgins 2011b).

Dealing with missing data

We contacted study authors to obtain missing statistical data. Outcomes were analysed using intention‐to‐treat results where possible. Where this was not possible, the data were analysed as reported by the study authors. We reported the number of participants lost to follow‐up and reasons given for attrition in each study as part of the 'Risk of bias' assessment. We calculated missing standard deviations (SDs), where possible, from other reported statistics (Higgins 2011c). Where this was not possible, the SD was imputed from the most representative study; i.e. the study with the greatest weight on the meta‐analysis. The possible impact on missing data on the findings of the review was investigated in sensitivity analyses, and discussed in the review (Higgins 2011b).

Assessment of heterogeneity

Before meta‐analysis, studies were assessed for clinical homogeneity with respect to type of multimedia program, control group, and the outcomes measured. Clinically heterogeneous studies were not combined in the analysis, but separately described. For studies judged as clinically homogeneous, we tested for statistical heterogeneity using the Chi² test. We interpreted the Chi² test as indicating significant statistical heterogeneity if the Chi² significance (P value) was less that 0.10. This value was chosen instead of the conventional significance level of 0.05 to counteract the low power of the Chi² test when meta‐analyses contain studies with small sample sizes or that are few in number. In order to assess and quantify the possible magnitude of inconsistency across studies, we examined the I² statistic. The I² statistic describes the percentage of the variability in effect estimates that is due to heterogeneity rather than sampling error. It was interpreted as: 0% to 40% representing heterogeneity that may not be important; 30% to 60% representing moderate heterogeneity; 50% to 90% representing substantial heterogeneity; 75% to 100% representing considerable heterogeneity (Deeks 2011).

Assessment of reporting biases

We planned to assess publication bias graphically using a funnel plot if there were at least 10 studies included in the meta‐analyses of the primary outcomes (knowledge and skill acquisition) (Sterne 2011). However, we identified fewer than 10 studies, precluding the analysis.

We assessed the potential for 'small sample' reporting bias by investigating whether the random‐effects model produced similar effect sizes as the fixed‐effect model. In the presence of small‐study effects, the intervention effect is more beneficial in the smaller studies, and the random‐effects estimate of the intervention effect will be more beneficial than the fixed‐effect estimate (Sterne 2011).

Data synthesis

All trials, regardless of their assessed risk of bias, were pooled in the primary analysis. We pooled studies using the random‐effects model due to the likely heterogeneity of the multimedia interventions being evaluated. We presented results for each of the outcomes, organised by the comparison intervention:

Multimedia compared to no education or usual care
Multimedia compared with other forms of education
1. written education
2. education by a health professional
3. written education and education by a health professional
Multimedia compared with 'control' multimedia program
Multimedia plus a co‐intervention compared with the co‐intervention alone

We used forest plots to illustrate the results of meta‐analyses where there was more than one study for that outcome. Where there was only one study for a particular outcome, we included the results in the text. We also presented results for all studies in Additional tables (Table 2).

Table 2. Study outcome data

Study	Study arms	Timing of follow‐up	N at follow‐up	Outcome	Results
Acosta 2009	Multimedia (I) vs control multimedia (C)	Immediately before (baseline) and after (post) the intervention and after one month.	I: 62 C: 54	Skill acquisition (inhaler technique)	Change in score (% correct) from baseline: Post intervention: I: 15.92 (SD 15.04), C: 1.16 (6.55), P < 0.001, mean difference 14.77, 95% CI 10.39 to 19.15. After 1 month: I: 14.92 (SD 15.49), C: 1.62 (SD 7.30) P < 0.001, mean difference 13.30 95% CI 8.74 to 17.86.
Acosta 2009	Multimedia (I) vs control multimedia (C)		I: 62 C: 54	Peak flow	Post intervention I: 403.45 (95% CI 392.40 ‐ 414.94), C: 382.21 (95% CI 370.42 ‐ 394.01). Results are "controlled for pre‐intervention peak flows". There was no significant difference in pre intervention peak flows readings (C: 409.81, I: 386.94, P = 0.18)
Deitz 2011	Multimedia (I) vs control (C)	After the intervention period	Total post‐test N = 346 I: 181 C: 165
			N (who completed the knowledge questionnaire) = 329	Knowledge of prescription drug use and dependency	Mean score (SD): Drug facts I: 13.23 (2.40), C: 12.84 (2.33), P = 0.025; Smart use I: 13.1 (1.63), C:12.9 (1.43), P = 0.457; Manage health I: 6.48 (0.96), C: 6.40 (0.89), P = 0.127. Maximum score for the scales was not reported.
			1. N = 345 2. N = 343 3. N = 342	Self efficacy: 1. Self‐efficacy in obtaining medical information and attention to their concerns from their doctor (PEPPI) 2. Medication adherence self‐efficacy (Medication Adherence Survey) 3. Self efficacy in managing medication problems (Ability to Manage Problems Survey)	1. Mean score (SD): I: 17.85 (4.33), C: 17.70 (4.30), P = 0.687. Maximum score for the scale was not reported. 2. Mean score (SD): I: 58.82 (11.88), C: 56.88 (11.72), P = 0.013. Maximum score for the scale was not reported. 3. Mean score (SD): I: 28.05 (3.99), C: 27.34 (3.83), P = 0.026. Maximum score for the scale was not reported.
			N = 345	Patients' perception of the therapeutic alliance with care givers and degree of satisfaction with treatment (Patient feedback survey)	Mean score (SD): I: 30.20 (5.81), C: 30.19 (5.05), P = 0.744. Maximum score for the scale was not reported.
			N = 344	Patients' perception of the degree of directive guidance (instructions on taking their medication properly) given by doctors and pharmacists (Purdue)	Mean score (SD): I: 17.27 (4.40), C: 17.01 (4.07), P = 0.749. Maximum score for the scale was not reported.
			N = 329	Patients' perception about their current drug use and whether it is problematic (CAGE)	Mean score (SD): I: 0.485 (0.83), C: 0.861 (1.19), P = 0.038. Maximum score for the scale was not reported.
			N = 344	Self reported drug taking for non‐medical purposes (sections of the NSDUH)	Odds ratio between intervention and control group (from logistic regression with pre‐intervention non‐medical use entered as a control variable): Non‐medical use of analgesics: OR 0.656, 95% CI 0.147 to 2.92, P = 0.579. Non‐medical use of sedatives: OR 1.41, 95% CI 0.50 to 3.97, P = 0.517. Non‐medical use of tranquillisers: OR 2.09, 95% CI 0.92 to 33.03, P = 0.132. Non‐medical use of stimulants: OR 6.47, 95% CI 0.426 to 98.13, P = 0.179.
Goodyer 2006	Multimedia (I) vs written and verbal (V) vs written (C)	Immediately before and after the intervention	I: 34 V: 35 C: 35	Skill acquisition (inhaler technique)	Change in global technique rating. Number who were: worse than baseline I: 5/34, V: 4/35, C: 5/35; same as baseline I: 12/34, V: 16/35, C: 18/35; better than baseline I: 17/34, V: 15/35, C: 9/35. Number who: check mouthpiece I: 16/34, V:11/35, C: 1/35; shake inhaler: I: 24/34, V: 35/35, C: 16/35; co‐ordination I: 11/34, V: 10/35, C: 3/35.
Kato 2008	Multimedia education (I) vs control multimedia (C)	Before the intervention as well as 1 and 3 months later	Number varies for each outcome for the 3 time points. Knowledge: I: 191, 172, 164 C: 168, 146, 139	Knowledge about cancer	Mean score (SD). Before I: 59% (20) C: 60% (20); 1 month I: 65% (20) C: 63% (20); 3 months I: 66% (20) C: 63% (20). Significantly greater increase in knowledge over time in intervention group (P = 0.035)
			CDCI: I: 191, 172, 163 C: 167, 147, 140 MAS: I: 190, 167, 160 C: 166, 146, 138	Self‐reported adherence to medications: 1. CDCI (Chronic Disease Compliance Instrument) 2. MAS (Medication Adherence Scale)	1. CDCI mean score (SD), range of 18‐90 with higher scores representing greater adherence: Before I: 79.2 (7.9), C: 77.4 (7.5); 1 month I: 79 (8.3), C: 78.4 (7.7); 3 months I: 81 (8.7), C: 78.4 (7.5). 2. MAS mean score (SD), range from 0‐4 with higher scores indicating greater adherence: Before I: 2.9 (1.1), C: 2.9 (1.1); 1 month I: 3.0 (1.1), C: 3.1 (1.0); 3 months I: 2.9 (1.1), C: 3.0 (1.1).
			6‐MP metabolite assays: I: 28, 24, 23 C: 26, 22, 23 MEMS (only measured at 3 months): I: 107 C: 93	Objective measures of adherence to medications: 1. 6 ‐MP adherence using metabolite assays: 6‐TG and 6‐MMP 2. TMP/SMX adherence using Medication Event Monitoring System (MEMS)	1. 6‐MP mean metabolite level (SD). 6‐TG: Before I: 250.7 (245.3) C: 284.3 (206.4); 1 month I: 283 (230.1), C: 302.1 (214); 3 months I: 286.5 (307.4), C: 236.8 (148.2). 6‐MMP: Before I: 10484.6 (9920.6) C: 9218 (11004.2); 1 month I: 11168.9 (12107.5), C: 10349.9 (11667.1); 3 months I: 8499.1 (7600.3), C: 8087.0 (9123.6). 2. MEMS mean (SD) % prescribed doses taken: At 3 months. I: 62.3% (62.9). C: 52.5% (37.6) Medication adherence did not differ significantly between groups when measured using self‐report: CDCI (P = 0.78), MAS (P = 0.503) but did differ significantly on objective measures: 6‐MP metabolites (P = 0.041), MEMS (P = 0.012).
				Clinic visit attendance	Mean: 98+/‐ 1% of scheduled visits were attended across both groups with no significant difference between the groups P = 0.65
			I: 191, 172, 164 C: 168, 148, 139	Self‐efficacy	Mean score (SD). Range 27‐189 with higher scores representing greater self‐efficacy. Before I: 155.9 (22.3), C: 156.6 (21.3); 1 month I: 158 (24.3), C: 157.9 ( 22.3); 3 months I: 164.1 (23.4), C: 158.8 (23.5). Significantly greater self‐efficacy in intervention group (P = 0.011).
			PQL: I: 154, 143, 119 C: 134, 119, 102 FACT‐G: I: 32, 25, 23 C: 31, 29, 25	Quality of life (QOL): 1. PQL (Paediatric Quality of Life) 2. FACT‐G (Functional Assessment of Cancer Therapy)	1. PQL: Mean score (SD). Range 0‐100 with higher score representing better QOL. Before I: 64.2 (15.4) C: 62.5 (17,4); 1 month 65.5 (15.1) C: 63.5 (17.6); 3 months I: 69.1 (15.1) C: 66.3 (17.3). 2. FACT‐G: Mean score (SD). Range 0‐108 with higher score representing better QOL. Before I: 11.3 (2.6), C: 10.7 (2.7); 1 month I: 11 (3.2) C: 11.1 (2.1); 3 months I: 12.2 (2.9), C: 11.3 (2.8). No significant difference between groups for QOL: PQL (P = 0.112), FACT‐G (P = 0.15).
			I: 191, 170, 162 C: 168, 146, 139	Perceived stress	Mean score (SD). Range 10‐50 with higher score representing more stress. Before I: 34.4 (7.4), C: 33.1 (6.6); 1 month I: 36.5 (6.6), C: 35.2 (6.8); 3 months I: 38.1 (6.9), C: 35.7 (6.2). No significant difference between groups (P = 0.931)
			I: 190, 171, 164 C: 168, 147, 139	Health Locus of Control Subscales: 1. Self/Internal 2. Chance 3. Powerful others 4. Doctors 5. Other people	Mean score (SD). Range 3‐36 for each sub‐scale with higher scores representing higher locus of control. Before I: 18.9 (6.1), C: 18.6 (5.3); 1 month I: 18 (5.9), C: 18.2 (5.8); 3 months I: 17.6 (6.6), C: 17.7 (6.2). Before I: 20.3 (6.6), C: 20.7 (7.3); 1 month I: 19.1 (6.1), C: 20 (6.6); 3 months I: 18.7 (6.8), C: 19.4 (6.9). Before I: 26.4 (4.7), C: 26.5 (4.6); 1 month I: 26.1 (5.1), C: 26.4 (4.6); 3 months I: 25.7 (5.3). C 26.2 (4.8). Before I: 15.2 (2.5) C:15.4 (2.6); 1 month I: 15 (2.8), C: 15.1 (2.8); 3 months I: 14.7 (2.9), C: 15 (2.6) Before I: 11.1 (3.4), C: 11.1 (3.5); 1 month I: 11.2 (3.4), C: 11.4 (3.2); 3 months I: 11 (3.7), C: 11.2 (3.3). No significant difference between groups on overall health locus of control score (P = 0.608).
Kinnane 2008	Multimedia and co‐intervention (I) versus co‐intervention alone (C)	At time of 2nd chemotherapy cycle (˜3 to 4 weeks post‐intervention)	I: 31 C: 29	Knowledge ‐ recall of content in the pre‐chemotherapy education. (results reported for each question).	No statistically‐significant difference in I and C group results for any question. The authors reported a trend towards higher recall in the video group for 3 questions: what mouth problems should be reported straight away (87% vs 78%, P = 0.45); symptoms of low red cell count (80.6% vs 66.7%, P = 0.29); prevention of constipation (74.2% vs 51.7%, P = 0.07).
Kinnane 2008			I: 31 C: 29	Use of health services	Number of patient phone calls to the chemotherapy centre I: 25, C: 27; Number of phone calls relating to education content I: 20/25, C: 15/27.
Knoerl 1999	Multimedia (I) vs usual care (C)	Preoperatively and 4, 8 and 24 hours postoperatively	I: 38 C: 38	Knowledge about PCA (measured pre and 4 hours post‐op)	Mean score (SD). Pre I: 65.4% (22.4), C: 56.6% (25.9), P = 0.13; Post I: 95.6% (8.4), C: 75.8% (17.6), P = 0.00.
				Attitude to pain medications (measured pre and 4 hours post‐op)	Mean score (SD) with higher score indicating more positive attitude. Pre I: 72% (28.5), C: 72% (28.2), P = 1.00; Post I: 95.6% (9.2), C: 72.4% (23.3), P = 0.00.
				Satisfaction with pain management	Mean (SD), range 1‐6 with high score representing low satisfaction: 4 hours post I: 1.4 (0.68), C: 1.8 (0.93), P = 0.03; 8 hours post I: 1.2 (0.37) C: 1.5 (0.60), P = 0.01; 24 hours post I: 1.2 (0.41), C: 1.5 (0.60), P = 0.10
				Pain	Mean pain rating (SD) from 0‐10 with 0 = no pain and 10 = worst possible pain. 4 hours post I: 4.0 (2.5), C: 5.3(3), P = 0.06; 8 hours post I: 3.2 (2.3), C: 3.9 (2.4), P = 0.27; 24 hours post I: 3.0 (2.1), C: 3.5 (2.1), P = 0.42.
				Incidence of medication side effects	Percent who experienced side effect: Nausea I: 42.1%, C: 34.2%, P = 0.48; vomiting I: 18.4%, C: 10.5%, P = 0.33; pruritis I: 28.9%, C: 34.2%, P = 0.63; hypotension I and C: 5.3%, P =1.0; sedation I: 21.1%, C: 28.9%, P = 0.43; urinary retention I: 10.5%, C: 13.2%, P = 0.73.
Lirsac 1991	Multimedia (I) vs verbal (C)	Before the intervention and after 15 days.	I: 14, C: 14	Inhaler technique	Mean change in inhaler technique score: I: ‐2.65, C: ‐1.65 (P < 0.05). Errors in inhaler technique following education (number of patients): I: 0 errors = 8, 1 error = 6. C: 0 errors = 6, 1 error = 4, 2 errors = 4. Mean inhaler technique score following education (SD ‐ estimated from figure) I:0.45 (0.5), C:0.85 (0.9). Baseline mean inhalation score was significantly better in the control group I: 3.1 (0.7), C: 2.5 (0.5), P < 0.05.
Lirsac 1991	Multimedia (I) vs verbal (C)	Before the intervention and after 15 days.	I: 14, C: 14	Bronchial obstruction	FEV: Baseline I: Pre MDI 1.89 (0.61), Post MDI 2.35 (0.74), C: Pre MDI 2.01 (0.7), 2.53 (0.84). 15 days after education I: Pre MDI 2.38 (0.84), Post MDI 2.66 (0.74), C: Pre MDI 2.09 (0.63), Post MDI 2.66 (0.74). Theoretical maximum FEV I: 2.73 (0.72), C: 3.14 (0.6)
Mazor 2007	Multimedia (I) vs usual care (C)	Before the intervention and 3 weeks later	Number varies for each outcome: I: 220, C: 87	Knowledge about warfarin	Mean score (SD) Before I: 57.5% (16), C: 54% (18) After I: 68.95% (16.07), C: 57% (17).
			I: 220, C: 86	Self‐reported non‐adherence to warfarin dosing	Percent reporting non‐adherence. Before I: 6.8%, C: 5.8%, After I: 3.6%, C: 3.5%
			I: 213, C: 85	Self‐reported intention to adhere to laboratory testing	Mean score (SD) range 1‐5 with higher score indicating stronger intent to adhere. Before I: 3.7 (1.1), C: 3.7 (1.0); After I: 3.93 (0.99), C: 3.81 (0.96).
			I: 175, C: 57	Non‐attendance at laboratory appointments	Number (%) not attending. Before I: 35/175 (20%), C: 10/57 (17.5%); After I: 38/175 (22%), C: 19/57 (33%).
			Subscale 1: I: 221, C: 89 Subscale 2: I: 219, C: 89 Subscale 3: I: 215, C: 85 Subscale 4: I: 221, C: 89	Beliefs about warfarin sub‐scales: 1. Belief warfarin is beneficial 2. Belief warfarin is worrisome 3. Belief warfarin regimen is confusing or difficult 4. Belief that laboratory testing is important	Mean scores (SD) with range 1‐5 with higher scores representing greater belief in benefit, less worry, confusion or difficulty and stronger belief in importance of testing. 1. Belief warfarin is beneficial: Before I: 3.45 (0.78), C: 3.47 (0.75); After I: 3.57 (0.8), C: 3.44 (0.74). 2. Belief warfarin is worrisome: Before I: 3.11 (0.94), C: 3.21 (0.89); After I: I:2.97 (0.98), C: 3.31 (0.85). 3. Belief warfarin regimen is confusing or difficult: Before I: 4.28 (0.55), C: 4.21 (0.63); After I: 4.27 (0.58), C: 4.19 (0.65) 4. Belief that laboratory testing is important: Before I: 4.16 (0.74), C: 4.06 (0.71); After I: 4.26 (0.68) C: 4.03 (0.7).
McElnay 1989	Multimedia plus written education (I) vs instruction by a health professional plus written education (V) vs written education (C)	Immediately after the intervention and 2 weeks later	Immediately after the intervention N = 50 in all three groups Two weeks later: I: 43 V: 40 C: 44	Skill acquisition (inhaler technique)	Immediately after the intervention (mean score out of 80 (SD)) I: 60 (14.85), V: 64.2 (6.36), C: 49.5 (13.44); P values: I vs V: P > 0.05, I vs C: P < 0.001; V vs C: P < 0.001 2 weeks later I: 50 (26.2), V: 59.5 (12.65), C: 47.3 (17.25); P values: I vs V: P > 0.05, I vs C: P < 0.05; V vs C: P < 0.001
Navarre 2007	Multimedia (I) vs usual care (C)	Immediately after the intervention	I: 18 C: 16	Knowledge of inhaler technique	Mean score (SD) I: 80.9% (17), C 67.4% (11.8), P = 0.01
Navarre 2007	Multimedia (I) vs usual care (C)	Immediately after the intervention	I: 18 C: 16	Skill acquisition (inhaler technique)	Mean score out of 100 (SD) I: 88.3 (12.3), C: 67.4 (19.2), P = 0.001
Neafsey 2001	Multimedia (I) vs usual care (C)	Immediately after the intervention	I: 30 C: 30	Knowledge about interaction of prescribed medications with OTC antacids and alcohol.	Mean score (SD) I: 71.7% (19.1), C: 36.2% (16.5), (P ≤ 0.001).
Neafsey 2001	Multimedia (I) vs usual care (C)	Immediately after the intervention	I: 30 C: 30	Self‐efficacy	Mean score (SD) scored from 1‐5 with higher scores representing greater self‐efficacy I: 3.14 (0.9), C: 1.76 (0.99), (P ≤ 0.001).
Neafsey 2002	Multimedia plus written information (I) vs written information (C)	Immediately after the intervention, 2 and 4 weeks later (except for risk of adverse medication behaviour which was assessed pre‐intervention, 2 and 4 weeks later)	I: 30 C: 30	Knowledge about interaction of prescription medications with OTC preparations and alcohol.	Mean score (SD) Post intervention I: 72.8% (16.8), C: 53.7% (18.7); At 2 weeks I: 77.6% (20.5), C: 55.2% (20); At 4 weeks I: 79.9% (21), C: 56.7% (20), P < 0.05 at all time points.
				Self‐efficacy	Mean score and SD (range 1‐5) with higher scores representing higher self‐efficacy. Post intervention I: 3.7 (0.8), C: 3.1 (0.95); At 2 weeks I:3.7 (0.8), C:2.8 (0.9), At 4 weeks I:3.9 (0.7), C:3.0 (0.8), P < 0.05 at all time points.
				Risk of adverse medication behaviour	Mean score and SD (range 0‐40) with higher score representing riskier behaviour Pre‐intervention I: 21 (11), C: 22 (14); At 2 weeks I: 18 (10.5), C: 22 (13); At 4 weeks I: 16 (10), C: 21 (10)
Olver 2009	Multimedia (I) vs written information (C)	3‐4 week after the intervention	I: 47 C: 54	Recall of information about chemotherapy	Number who answered each question correctly. Number of drugs I: 26/47 C: 25/54, P = 0.43. Treatment length I: 30/47, C:27/54, P = 0.23. Treatment goal I: 25/47, C: 31/54, P = 0.69.
				Satisfaction with information	Across both groups 66.4% found the information very or somewhat helpful and 53.5% felt that is was the right amount. Authors stated that there was no significant difference between groups on these variables.
				Usability of the information	Across both groups 45.5% read all of the information and 27.7% felt they understood all of the information. Authors stated that there was no significant difference between the groups in these variables.
				Anxiety level	Across both groups 30% felt the information dispelled their anxiety, 33% felt no different and 11% became more anxious. Authors stated that there was no significant difference between the groups.
Osguthorpe 1983	Multimedia plus written information (I) vs written information alone (W) Multimedia alone (I) vs usual care (C)	One week before and after the intervention	N = 202. The number in each arm was not reported	Knowledge about psychiatric medications.	Mean change scores from baseline for individual questions in each cluster were reported. The authors stated that there were no differences between groups based on total change scores but these were not reported.
Powell 1995	Multimedia (I) vs usual care (C)	Time of enrolment to completion of the study or termination from the HMO plan (maximum 9 months)	I: 1993 C: 2253	Compliance using the Medication Possession Ratio (MPR): the number of days' supply of medication obtained by patient divided by the number of days the patient was observed.	Mean MPR (SD) I: 0.70 (0.23), C: 0.70 (0.28). Number with MPR ≥ 0.8 I: 917 (46%), C: 998 (44%)
Savage 2003	Multimedia (I) vs written education (C)	Immediately before and after the intervention	I: 52 C: 43	Skill acquisition (inhaler technique)	Change in global inhaler technique rating: number worse than baseline I: 2/52, C: 4/43; same as baseline I: 27/52, C: 31/43; better than baseline I: 23/52, C: 8/43. Number who checks mouthpiece I: 10/52, C: 3/43; shakes inhaler I: 41/52, C: 32/43; coordination I: 28/52, C: 12/43; breathes in I: 27/52, C: 18/43.
Schnellinger 2010	Multimedia (I) vs written (P) vs control (C)	Immediately before (pre) and after (post) the intervention and after 4 weeks	Post: I: 83 P: 79 C: 84 At 4 weeks: I: 65 P: 63 C: 61	Knowledge about appropriate antibiotic use	Median score out of 10 (range): Pre I: 9 (2‐10), P: 8 (1‐10), C: 8 (1‐10), Post I: 10 (2‐10), P: 10 (1‐10), C: 8 (0‐10), 4 weeks I: 10 (2‐10), P: 9 (2‐10), C: 8 (1‐10). Numbers who had perfect scores at baseline I: 20 (31%), P: 13 (21%), C: 11 (18%). Number who improved following intervention (based on pre and post scores): I: 38 (58%), P: 45 (71%), C: 17 (28%). With percentages calculated after excluding participants with perfect scores at baseline: I: 85%, P: 90%, C: 34%.
Schnellinger 2010	Multimedia (I) vs written (P) vs control (C)			Evaluation survey	Percent answering yes: Q1. Found the study useful/interesting I: 93, P: 95, C: 80. Q2. Learnt something new about antibiotics I: 72, P: 84, C: 30. Q3. Paediatrician talked about proper use of antibiotics I: 59, P: 33, C: 70. Q4. Paediatrician talked about improper antibiotic use I: 61, P: 58, C: 66. Q5. Paediatrician offered antibiotics more often than needed I: 11, P: 11, C: 16. Q6. Would you ask Paediatrician for antibiotics for conditions mentioned in study (where antibiotics are not appropriate) I: 15, P: 35, C: 45. Q7. Do you think there is an antibiotic for every infection I: 12, P: 10, C: 12. Q8. Did you know about antibiotic resistance prior to the study I: 76, P: 63, C: 63. Q9. If you knew that doctor would not give an antibiotic would you still go to the doctor I: 58, P: 56, C: 51.
Schwarz 2008a	Multimedia education (I) vs control multimedia (C)	Before and 6 months after the intervention	I: 127 C: 138	Knowledge about emergency contraception (EC)	Number who learned: one or more things about EC I: 97/127 (76%), C: 86/138 (62%), P = 0.04. Mean scores baseline I:59%, C:62%, P = 0.12. Mean scores 6 months I:59%, C:58%, P = 0.88. EC is available in California I: 24%, C: 18%, P = 0.36; EC is safe I: 26%, C: 12%, P < 0.001; EC is effective I: 22%, C: 14%, P = 0.29; EC will not adversely affect future fertility I: 37%, 20%, P = 0.005; EC will not cause birth defects or miscarriage I: 34%, C: 14%, P < 0.001; EC can be used 3‐5 days after condom breaks I: 28%, C: 19%, P = 0.005; EC does not protect from STD I: 11%, C: 6%, P = 0.31; A period is expected within 3 weeks of taking EC I: 20%, C: 14%, P = 0.33.
				Attitude to EC	Number (%) who had personal objection to EC pre‐intervention: I: 19/219 (9%) C: 13/227 (6%). Number (%) who developed a more positive attitude toward EC after the intervention I:10/219 (8%), C: 6/227 (4%), P = 0.06.
				Self‐reported use of EC during study period	Number who used EC I: 6%, C: 3%, P = 0.09 Number who had supply of EC in the home I: 34%, C: 7%, P < 0.001.
				Conception during study period	Number who conceived I: 2.7%, C: 5.7%, P = 0.12.
Self 1983	Multimedia (I) vs education by a health professional (V) vs written education (C)	All groups assessed immediately after the intervention. I and V groups also assessed between 1‐16 weeks later.	Immediately after: I: 10 V: 9 C: 10 1‐16 weeks later: I: 8 V: 7	Skill acquisition (inhaler technique)	Mean inhaler technique score out of 20. Immediately after the intervention (SD) I: 16.9 (5.0), V: 16.8 (4.5), C: 10.7 (4.5). 1‐16 weeks later I: 14.3 (5.8), V: 17.4 (2).
Solomon 1988	Multimedia plus verbal instruction from doctor +/‐ special pill packaging (I) vs verbal instruction from doctor +/‐ special pill packaging (C)	2 or 6 days after starting the medication	N = 321, 38 to 42 participants in each of the 8 groups and approximately half exposed to the multimedia intervention.	Knowledge about tetracycline for treatment of STDs	Mean score out of 15. I: 14.4, C: 10.7. ANOVA F‐ratio = 442.7, P < 0.001.
				Non‐compliance with medication	Mean score (range 0‐160 with higher scores indicating worse compliance) I: 8.3, C: 40.45. Authors reported that the multimedia group had better compliance based on ANOVA result (F‐ratio = 114.2, P < 0.001).
				Premature resumption of sexual activity	Median percentage who resumed sexual activity prematurely I: 3%, C: 22%, ANOVA F‐ratio = 30.2, P < 0.001.
				Satisfaction with care	Authors reported that results for these variables were significantly improved in patients who had received multimedia education and/or special pill packaging compared to patients who had received neither: F (1312) = 5.1 P < 0.025.
				Perception of disease severity	F(1312) = 5.1 P < 0.026
				Confidence in medication	F(1312) = 6.1 P < 0.015
Stone 1989	Multimedia (I) vs education by a health professional (C)	Immediately before and after the intervention	I: 9 C: 13	Knowledge about warfarin	Mean score out of 18 (SD) Before I:12.6 (2.6), C:12.8 (1.4); After I:15.6 (1.4), C:16 (1.4), P = 0.60.
				Satisfaction with education	Mean score out of 25 I: 23.2, C: 24.8 Authors state that there was no significant difference.
				Use of health services	Time required for teaching (mean time in minutes) I: 17.6 (duration of video), C:26 (5.7) (mean (SD) duration of nurse lecture). Time required for questions after education (mean time in minutes) I: 7.5 (7.2) C: 6.3 (5.3)
Trent 2010	Multimedia plus usual care (I) vs usual care alone (C)	After two‐week treatment period	I: 36 C: 41	Adherence with medications	Number that completed the medication course: I: 23 (64%), C: 27 (66%).
				Attendance at 72 hour clinical visit	Number who attended: I: 11 (31%), C: 6 (15%).
				Abstinence from intercourse	Number who abstained: I: 25 (69%), C: 31 (76%)
				Partner notification	Number who notified partner: I: 30 (83%). C: 35 (85%)
				Partner treatment	Number who reported that partner had been treated: I: 24 (67%), C: 20 (49%)
				Complications	Number who reported complications: I: 13 (36%), C: 13 (32%).
Van Der Palen 1997	Multimedia (I) vs education by a health professional (V) vs usual care (C)	At first scheduled clinic visit up to 9 months later	I: 38 V: 77 C: 33	Skill acquisition (inhaler technique)	Mean inhaler checklist scores I: 91%, V: 91%, C: 74%; Essential checklist items (mean score) I: 92%; V: 95% C: 76%; Percent of patients with a 100% score I: 76%, V: 86%, C: 49%.
Voris 1982	Multimedia (I) vs usual care (C)	Before the intervention, and both 1‐5 days and 4 weeks after the intervention	After 1‐5 days: I: 6 C: 5 After 4 weeks: I: 4 C: 4	Knowledge about tricyclic antidepressants.	After 1‐5 days (mean score out of 20 (and range)) I: 19 (18‐20), C: 13.6 (8‐17); After 4 weeks I: 17.3 (16‐19), C: 12.8 (7‐18).

We used narrative synthesis where studies were not suitable for meta‐analysis, presented by comparison. For example, if the mean and SD could not be extracted for continuous outcomes, we presented the summary statistic and measure of variance, where available. These data were also presented in Additional tables (Table 2). If no data could be extracted from a study, we reported this in the notes section of the Characteristics of included studies table.

We used 'Summary of findings' tables to present the main results for each of the comparison groups, as recommended by the Cochrane Collaboration (Schünemann 2008a). We selected the following outcomes as the most important, and included them in 'Summary of findings' tables:

patient or carer knowledge about the medication;
skill acquisition;
compliance;
disease‐related outcomes;
adverse effects related to the medication,
quality of life, and
self‐efficacy.

Each table contains information about the number of studies and participants included, the outcome being examined, the magnitude of effect, and a GRADE assessment of the quality of evidence for each outcome (Schünemann 2008b).

Within each of these comparison groups, we explored possible reasons for variability of findings. These possible effect modifiers included the type or quality of the intervention, or variations in the characteristics of the population studied, including those outlined in the secondary objectives (age, literacy or disease chronicity).

Subgroup analysis and investigation of heterogeneity

Subgroup analyses were planned according to:

age group (examining the effect on the elderly (over 65 years) compared to those in other age groups);
literacy (groups with low literacy compared to others);
medications treating acute or chronic conditions;
specific characteristics of the multimedia intervention according to:
- degree of interactivity:
  - not interactive; e.g. video or DVD that can only be watched from beginning to end
  - limited interactivity; e.g. DVD or computer program where the individual can choose the information components that they want to access and the order in which they access them
  - fully interactive; in which the responses of the program are constantly changing in response to user actions e.g. a computer game or simulation
- tailoring (where the information provided is personalised, based on an individual's characteristics) versus generic information

Sensitivity analysis

We performed sensitivity analyses to examine the effect of adequate allocation concealment and blinding of outcome assessor (trials with low risk of bias) on effect size for the primary outcomes. We also performed sensitivity analyses to investigate the effect of imputation of missing data (e.g. SD). Where the random‐effects model was used, we repeated the analysis using a fixed‐effect model and compared the results to examine the influence of small‐study effects on the intervention effect estimate.

Consumer participation

We collected information about consumer involvement in the development of the educational interventions. As part of the standard editorial process of the Cochrane Consumers and Communication Review Group, the protocol (Ciciriello 2010) and this review were reviewed by a consumer referee. A consumer representative was a co‐author for this review (TdK). She reviewed the protocol and provided input on how it could be improved so that it was more relevant to consumers. She also contributed to the synthesis of results and was part of the team that wrote the review.

Results

Description of studies

Results of the search

The search strategies identified 6113 studies (to June 2011), with 4562 remaining once duplicates were removed. We identified a further 977 studies when the search was updated to the end of June 2011, bringing the total to 5539 and leaving 5529 once duplicates were removed. Of these, 5346 were excluded as they were judged as not relevant to the review based on information in the study title and abstract, leaving 193 references for which the full text was retrieved. On examination of the full text, we identified 71 studies as clearly not fulfilling the inclusion criteria for this review. We excluded these studies because they were not randomised or quasi‐randomised controlled trials (N = 57) or did not contain any multimedia intervention (N = 14). We examined the remaining 122 studies in greater detail, from which 24 studies were found that met all inclusion criteria for this review. We outline the reasons for exclusion of the other studies below (Excluded studies). No further studies meeting criteria for inclusion were found following examination of the references of included studies or relevant reviews (those identified as potentially overlapping with the current review and those identified from current database searches). We illustrate the results of the search strategy and screening process in Figure 1.

Figure 1

Study flow diagram.

We were able to contact 10 of the study authors to request further information. All 10 authors were contacted to request access to the multimedia educational program. This was provided by six authors (Deitz 2011; Kinnane 2008; Mazor 2007; Navarre 2007; Olver 2009; Trent 2010), while three authors provided copies of the voice‐over script (Goodyer 2006; Savage 2003; Schwarz 2008a) and one author informed us that the multimedia program was no longer available (Van Der Palen 1997). Further outcome data were requested from 4 of the 10 authors. One author was able to provide this information (Schwarz 2008a), while three authors informed us that this information was not available (Deitz 2011; Kinnane 2008; Olver 2009).

Included studies

We included 24 studies. Study characteristics are summarised below. Key participant and intervention characteristics are summarised across the studies in Table 3 and outlined in more detail for each of the individual studies in the Characteristics of included studies tables. Study duration varied from one day to nine months and the studies were published from 1982 to 2011. English was the first language of participants, and therefore the only language in which education was provided, in all but five studies (Acosta 2009; Goodyer 2006; Kato 2008; Lirsac 1991; Van Der Palen 1997). .

Table 3. Summary of key participant and intervention characteristics across included studies

Characteristics of study participants
Characteristic		Number of studies	Study titles
Country in which study is set	USA	16	Acosta 2009; Deitz 2011; Knoerl 1999; Mazor 2007; Navarre 2007; Neafsey 2001; Neafsey 2002; Osguthorpe 1983; Powell 1995; Schnellinger 2010; Schwarz 2008a; Self 1983; Solomon 1988; Stone 1989; Trent 2010; Voris 1982
	United Kingdom	3	Goodyer 2006; McElnay 1989; Savage 2003
	Australia	2	Kinnane 2008; Olver 2009
	Netherlands	1	Van Der Palen 1997
	France	1	Lirsac 199
	Multi‐centre study in the USA, Canada and Australia	1	Kato 2008
Setting from which participants were recruited	Community or hospital‐based outpatient clinics, treatment centres and inpatient wards	15	Kato 2008; Kinnane 2008; Knoerl 1999 Lirsac 1991; Mazor 2007; Navarre 2007; Olver 2009; Osguthorpe 1983; Savage 2003; Self 1983; Solomon 1988; Stone 1989; Trent 2010; Van Der Palen 1997; Voris 1982
	Emergency departments or urgent care clinics	3	Acosta 2009; Schnellinger 2010; Schwarz 2008a
	Local seniors centres	2	Neafsey 2001; Neafsey 2002
	Turkish social clubs	1	Goodyer 2006
	HMO members who had pharmacy claims for particular medications	1	Powell 1995
	Volunteers from staff at participating hospitals	2	Deitz 2011; McElnay 1989
Gender	Only women	3	Deitz 2011; Schwarz 2008a; Trent 2010
Gender	Only men	1	Osguthorpe 1983
Age	Adults only (17 years or older). Three studies dealt with specific age groups; Neafsey 2001 and Neafsey 2002 recruiting seniors aged 60 years or older and Schwarz 2008a recruiting women of childbearing age (aged 18 to 45 years)	19	Acosta 2009; Deitz 2011; Goodyer 2006; Kinnane 2008; Knoerl 1999; Mazor 2007; McElnay 1989; Navarre 2007; Neafsey 2001; Neafsey 2002; Olver 2009; Osguthorpe 1983; Powell 1995; Schnellinger 2010; Schwarz 2008a; Self 1983; Stone 1989; Van Der Palen 1997; Voris 1982
Age	Also recruited children. Kato 2008 recruited children, adolescents and young adults aged 13 to 29 years, Trent 2010 recruited adolescents aged 15 to 21 years, Savage 2003 included patients aged 12 to 87 years old, Lirsac 1991 recruited participants aged 10 to 71 years old and Solomon 1988 included participants aged 14 to 59 years old (mean age 23).	5	Kato 2008; Lirsac 1991; Savage 2003; Solomon 1988; Trent 2010
Language in which education was provided	English	19	Deitz 2011; Kinnane 2008; Knoerl 1999; Mazor 2007; McElnay 1989; Navarre 2007; Neafsey 2001; Neafsey 2002; Olver 2009; Osguthorpe 1983; Powell 1995; Savage 2003; Schnellinger 2010; Schwarz 2008a; Self 1983; Solomon 1988; Stone 1989; Trent 2010; Voris 1982
	Dutch	1	Van Der Palen 1997
	Turkish	1	Goodyer 2006
	French	1	Lirsac 1991
	More than one language (Kato 2008 using English, French or Spanish and Acosta 2009 using both English and Spanish)	2	Acosta 2009; Kato 2008
Educational level	Mean number of years of education completed. Combined results from the 4 studies showed that the 243 participants completed a mean of 13.5 years of education.	4	Knoerl 1999; Neafsey 2001; Neafsey 2002; Stone 1989
	Highest level of education completed. Of the combined 2616 participants from the 11 studies, 49% had completed some primary or secondary school while 48% had attended tertiary level education.	11	Acosta 2009; Deitz 2011; Kato 2008; Kinnane 2008; Mazor 2007; Navarre 2007; Olver 2009; Osguthorpe 1983; Schnellinger 2010; Schwarz 2008a; Solomon 1988
	Low versus high level. One study reported that 82% of its 148 participants had a low educational level and 18% had a high level but did not provide definitions for these levels.	1	Van Der Palen 1997
	Participants' level of educational attainment was not reported.	8	Goodyer 2006; Lirsac 1991; McElnay 1989; Powell 1995; Savage 2003; Self 1983; Trent 2010; Voris 1982
Literacy	Comprehension score of at least grade six on the Rapid Estimate of Adult Literacy Measure (REALM)	2	Neafsey 2001; Neafsey 2002
	One study reported that over 80% of the participants were literate in Turkish when assessed using a language proficiency test devised by their language department.	1	Goodyer 2006
	No information reported about literacy	21	All other studies
Primary diagnosis and treatment; topic of the educational program	Respiratory illnesses treated with metered dose inhalers (MDIs); MDI technique	7	Acosta 2009; Goodyer 2006; Lirsac 1991; Navarre 2007; Savage 2003; Self 1983; Van Der Palen 1997
	Malignancies treated with chemotherapy; chemotherapy and management of its side effects	3	Kato 2008; Kinnane 2008; Olver 2009
	Conditions requiring anticoagulation with warfarin; warfarin	2	Mazor 2007; Stone 1989
	Psychiatric illnesses treated with specific medications; specific psychiatric medications	2	Osguthorpe 1983; Voris 1982
	Elderly patients taking particular over‐the‐counter medications e.g. antacids and pain relievers; interaction between prescription and over‐the counter medications	2	Neafsey 2001; Neafsey 2002
	Sexually transmitted diseases (STD) or pelvic inflammatory disease (PID) treated with antibiotics; treatment of STD or PID with antibiotics	2	Solomon 1988; Trent 2010
	Hypertension, hypercholesterolaemia or menopause treated with specific medications; specific medications for these conditions	1	Powell 1995
	Undergoing a surgical procedure requiring post‐operative patient‐controlled analgesia (PCA); PCA	1	Knoerl 1999
	Did not require participants to have a particular medical condition or to have taken a particular medication: female hospital employees ‐ education about medications with abuse potential including strategies for avoiding drug use and dependence; volunteers with no experience of MDI use ‐ education about MDI technique; parents of children presenting for acute care ‐ education about proper antibiotic use; women of child‐bearing age attending emergency department ‐ education about emergency contraception.	4	Deitz 2011; McElnay 1989; Schnellinger 2010; Schwarz 2008a
Acuity of the primary diagnosis	Acute	3	Knoerl 1999; Solomon 1988; Trent 2010
	Chronic	16	Acosta 2009; Goodyer 2006; Kato 2008; Kinnane 2008; Lirsac 1991; Mazor 2007; Navarre 2007; Neafsey 2002; Olver 2009; Osguthorpe 1983; Powell 1995; Savage 2003; Self 1983; Stone 1989; Van Der Palen 1997; Voris 1982
	Unclear	1	Neafsey 2001
Characteristics of interventions
Format	Video: 10 studies used videotapes, two studies DVDs and two studies did not report the technology used to deliver the video.	14	Acosta 2009; Kinnane 2008; Knoerl 1999; Lirsac 1991; Mazor 2007; McElnay 1989; Osguthorpe 1983; Powell 1995; Schnellinger 2010; Self 1983; Solomon 1988; Stone 1989; Trent 2010; Van Der Palen 1997
	Computer‐based program: four studies used programs with touch‐screen technology and the program used in one study was a computer game.	9	Deitz 2011; Goodyer 2006; Kato 2008; Navarre 2007; Neafsey 2001; Neafsey 2002; Olver 2009; Savage 2003; Schwarz 2008a
	Slide audiovisual presentation	1	Voris 1982
Source of the multimedia program	Developed by the study authors	19	Deitz 2011; Goodyer 2006; Kato 2008; Kinnane 2008; Mazor 2007; McElnay 1989; Navarre 2007; Neafsey 2001; Neafsey 2002; Olver 2009; Osguthorpe 1983; Savage 2003; Schnellinger 2010; Schwarz 2008a; Self 1983; Solomon 1988; Stone 1989; Trent 2010; Voris 1982
	Developed by other organisations ‐ pharmaceutical companies and a national medical media company	2	Powell 1995; Van Der Palen 1997
	Not reported	3	Acosta 2009; Knoerl 1999; Lirsac 1991
Consumer involvement in development of the program	Studies that reported consumer involvement in the development of the multimedia program	6	Kato 2008; Mazor 2007; McElnay 1989; Neafsey 2001; Neafsey 2002; Trent 2010
Number of times the multimedia program was viewed and success at reaching target audience	All participants viewed the program on at least one occasion	20	Acosta 2009; Goodyer 2006; Kinnane 2008; Knoerl 1999; Lirsac 1991; McElnay 1989; Navarre 2007; Neafsey 2001; Neafsey 2002; Olver 2009; Osguthorpe 1983; Savage 2003; Schnellinger 2010; Schwarz 2008a; Self 1983; Solomon 1988; Stone 1989; Trent 2010; Van Der Palen 1997; Voris 1982
	Known number of participants who did not view the program on at least one occasion ‐ 4% (Deitz 2011), 13% (Kato 2008)	2	Deitz 2011; Kato 2008
	Number who did not view the program not known ‐ Powell 1995 sent a questionnaire to a subset of 205 of the 1993 participants of which 97 (47%) were returned. Of these, 13% reported that they had not viewed the video.	2	Mazor 2007; Powell 1995
	Rates of repeat viewing of the program reported ‐ 36.2% and 88% viewed program more than once in Olver 2009, Deitz 2011 respectively, 33% viewed program for the requested duration of one hour/week in Kato 2008 and the program was viewed a median of three times (range 1 to 50) in Van Der Palen 1997	4	Deitz 2011; Kato 2008; Olver 2009; Van Der Palen 1997
	Rates of repeat viewing not measured or reported	2	Mazor 2007; Powell 1995
Assistance from staff	Studies reporting that research staff or health professionals provided assistance in viewing or using the multimedia program	4	Goodyer 2006; Navarre 2007; Olver 2009; Savage 2003
Degree of interactivity of the computer based programs (none of the programs using other formats contained any interactive features)	Limited	6	Goodyer 2006; Neafsey 2001; Neafsey 2002; Olver 2009; Savage 2003; Schwarz 2008a
	Sections with both limited and full interactivity	1	Deitz 2011
	Full	1	Kato 2008
	Not reported	1	Navarre 2007
Tailoring	Program tailored to an individual users' characteristics	2	Deitz 2011; Olver 2009

Participants

The 24 included studies enrolled a total of 8112 participants. Sample sizes for the trials varied from 11 (Voris 1982) to 4246 participants (Powell 1995). Nineteen of the studies involved only adults, while five studies also recruited children (Kato 2008; Lirsac 1991; Savage 2003; Solomon 1988; Trent 2010). Four of the studies selected participants of a particular gender: Deitz 2011; Schwarz 2008a and Trent 2010 only included women while Osguthorpe 1983 only included men admitted to a Veterans' psychiatric hospital.

Only three studies reported patients' literacy levels. Neafsey 2001 and Neafsey 2002 recruited only participants who had a reading comprehension score of at least grade six on the Rapid Estimate of Adult Literacy Measure (REALM). Goodyer 2006 reported that over 80% of the participants were literate in Turkish when assessed using a language proficiency test devised by the language department at King's College London.

Twenty of the studies recruited patients who were taking, or were about to start taking, particular medications for a variety of medical conditions. Only 3 of these 20 studies were performed in patients with acute conditions (Knoerl 1999; Solomon 1988; Trent 2010), the chronicity of the underlying conditions was unclear in Neafsey 2001, and the other 16 studies dealt with chronic conditions. The remaining four studies recruited participants who were not necessarily taking the medication under consideration at the time. Of these, three studies recruited demographic groups that were likely to have taken the relevant medication or to require them in the future. This included female hospital employees (Deitz 2011), parents of children presenting to an emergency department for acute care (Schnellinger 2010), and women of childbearing age who were attending two urgent care clinics for any reason (Schwarz 2008a). One study recruited healthy volunteers who were not taking the relevant medication and were unlikely to require it in the future (McElnay 1989).

Thirteen studies reported that they had obtained institutional ethics approval and informed consent from the study participants (Acosta 2009; Kato 2008; Kinnane 2008; Knoerl 1999; Goodyer 2006; Olver 2009; Navarre 2007; Savage 2003; Schnellinger 2010; Schwarz 2008a; Solomon 1988; Trent 2010; Van Der Palen 1997). Five studies reported informed consent but did not provide information about ethics approval (Deitz 2011; Neafsey 2001; Neafsey 2002; Osguthorpe 1983; Voris 1982). One study reported ethics approval but not informed consent (Mazor 2007) and five studies reported neither ethics approval nor informed consent (Lirsac 1991; McElnay 1989; Powell 1995; Self 1983; Stone 1989).

Interventions

The multimedia interventions consisted of videos in 14 studies (Acosta 2009; Kinnane 2008; Knoerl 1999; Lirsac 1991; Mazor 2007; McElnay 1989; Osguthorpe 1983; Powell 1995; Schnellinger 2010; Self 1983; Solomon 1988; Stone 1989; Trent 2010; Van Der Palen 1997), computer‐based programs in 9 studies (Deitz 2011; Goodyer 2006; Kato 2008; Navarre 2007; Neafsey 2001; Neafsey 2002; Olver 2009; Savage 2003; Schwarz 2008a), including a computer game (Kato 2008), and in 1 study a slide‐tape audiovisual presentation (Voris 1982).

The length of the videos ranged from 3 minutes (Schnellinger 2010) to 30 minutes (Powell 1995). The complexity of the computer‐based programs also varied from short videos accompanied by text and voice‐over, to programs that provided detailed information utilising text, still graphics, animations and video and broken into multiple sections through which the user was able to navigate freely.

The usage of the programs also varied. In 20 studies all of the participants viewed the multimedia program on at least one occasion (Acosta 2009; Goodyer 2006; Kinnane 2008; Knoerl 1999; Lirsac 1991; McElnay 1989; Navarre 2007; Neafsey 2001; Neafsey 2002; Olver 2009; Osguthorpe 1983; Savage 2003; Schnellinger 2010; Schwarz 2008a; Self 1983; Solomon 1988; Stone 1989; Trent 2010; Van Der Palen 1997; Voris 1982). In six studies the participants had the opportunity to view the program on more than one occasion if they wished (Deitz 2011; Kato 2008; Mazor 2007; Olver 2009; Powell 1995; Van Der Palen 1997). However, rates of repeat usage varied. For example, Olver 2009 and Van Der Palen 1997 reported that the multimedia program was viewed more than once by 36.2% and 88% of participants respectively.

Information about the program's degree of interactivity or tailoring was able to be determined for eight of the studies using computer‐based multimedia interventions. Six of the computer programs allowed limited interactivity, with users having some control over the order in which they accessed content and the pace at which they moved through the program (Goodyer 2006; Neafsey 2001; Neafsey 2002; Olver 2009; Savage 2003; Schwarz 2008a). The program used in Deitz 2011 also contained fully interactive components where users could determine their fitness level and determine if they needed help with their use of prescription medication. The program used in Kato 2008 was a fully interactive computer game, with the actions of users determining the direction that the game takes. Two programs were tailored to an individual users' characteristics (Deitz 2011; Olver 2009).

The educational content of the multimedia programs focused on metered dose inhaler (MDI) technique in eight studies (Acosta 2009; Goodyer 2006; Lirsac 1991; McElnay 1989; Navarre 2007; Savage 2003; Self 1983; Van Der Palen 1997), chemotherapy and the management of its side effects in three studies (Kato 2008; Kinnane 2008; Olver 2009), anticoagulation therapy with warfarin in two studies (Mazor 2007; Stone 1989) and the interaction between alcohol, over‐the‐counter medications and prescription medications in two studies (Neafsey 2001; Neafsey 2002). The remaining studies each dealt with a different topic.

Six of the studies reported consumer involvement in the development of the multimedia program (Kato 2008; Mazor 2007; McElnay 1989; Neafsey 2001; Neafsey 2002; Trent 2010).

Evaluation of the educational interventions using the Evaluative Linguistic Framework (ELF)

The 24 studies used 22 different multimedia educational interventions. Six of the multimedia programs were available or were provided by the study authors (Deitz 2011; Kinnane 2008; Mazor 2007; Navarre 2007; Olver 2009; Trent 2010). Program evaluation was based on the voice‐over script for three programs that were used in four studies (Goodyer 2006; Savage 2003; Schwarz 2008a; Voris 1982) and from information provided on a website (including the user manual, screen shots and short video excerpts) for one study (Kato 2008). Evaluations of the remaining 12 multimedia programs were based on descriptions provided by the authors in the published studies. The detail in which the characteristics of the multimedia program were reported varied. The information provided in six studies was insufficient to allow any evaluation of the multimedia program (Acosta 2009; Knoerl 1999; Lirsac 1991; Schnellinger 2010; Self 1983; Van Der Palen 1997). Five studies provided information which allowed evaluation which was mostly limited to the program's generic structure and format (McElnay 1989; Osguthorpe 1983; Powell 1995; Solomon 1988; Stone 1989). The multimedia program used in two studies (Neafsey 2001; Neafsey 2002), was evaluated based on information from a publication describing the program's development and testing (Strickler 2002). We present detailed information regarding the quality of the multimedia programs in Additional tables (Table 4).

See: Summary of findings for the main comparison Summary of findings: multimedia education compared with no education or usual care; Summary of findings 2 Summary of findings: multimedia education compared with written education; Summary of findings 3 Summary of findings: multimedia education compared with education by a health professional; Summary of findings 4 Summary of findings: multimedia education compared with written education and education by a health professional; Summary of findings 5 Summary of findings: multimedia education compared with control multimedia; Summary of findings 6 Summary of findings: multimedia education and a co‐intervention compared with co‐intervention alone

Table 4. Description and evaluation of interventions

Study

Intervention

Comparators

Acosta 2009

Source of information about intervention: Information provided by the author in the published thesis.

Description of intervention: Video demonstrating steps for correct MDI use.

Name of program: Not reported

Country of origin: USA

Language: English and Spanish

Year program used in the study was produced: Not reported

Stated expertise of content developers: Not reported

Stated expertise of program developers: Not reported

Process of development and testing: Not reported.

Availability: Not reported

Purpose: To demonstrate correct inhaler technique to patients with asthma

Content: Video containing pictures describing the different steps in properly using an MDI.

Relationship between developer and user: Health professionals to patients.

Target audience: Asthma patients

Format: Video

Hardware required: Television and video player

Media: Video and audio

Delivery: Viewed on site in the emergency department

Length of program: 10 minutes

Number of times program was used: Patients only viewed the video on one occasion.

Time point of delivery: Participants had existing asthma therefore it is assumed that they were using MDIs prior to the study. 58% had previously received training about correct use of an MDI.

Success at reaching target audience: The video was administered on site therefore all participants in the intervention arm viewed the program.

Assistance: Not reported

Interactivity: No

Tailoring: No

Source of information about comparators: Information provided by the author in the published thesis

Description of comparator: Video about asthma.

Name of program: Not reported

Country of origin: USA

Language: English and Spanish

Year program used in the study was produced: Not reported

Stated expertise of content developers: Not reported

Stated expertise of program developers: Not reported

Process of development and testing: Not reported.

Availability: Not reported

Purpose: To provide general information about asthma and its triggers.

Content: Video explains issues faced by patients with asthma and asthma triggers but does not contain any MDI related instructions.

Relationship between developer and user: Health professionals to patients.

Target audience: Asthma patients

Format: Video

Hardware required: Television and video player

Media: Video and audio

Delivery: Viewed on site in the emergency department

Length of program: 10 minutes

Number of times program was used: Patients only viewed the video on one occasion.

Time point of delivery:

Success at reaching target audience: The video was administered on site therefore all participants in the control arm viewed the program.

Assistance: Not reported

Interactivity: No

Tailoring: No

Evaluation of intervention:

Inadequate information was provided on which to base an assessment

Evaluation of comparator:

Inadequate information was provided on which to base an assessment

Deitz 2011

Source of information about intervention: Copy of the program as well as information provided by the author in the published study.

Description of intervention: Multimedia program designed to prevent the misuse of psychoactive prescription drugs.

Name of program: SmartRx: Your Prescription for Good Health

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Although this was not explicitly stated, the study implied that the multimedia program was developed by the study authors. The study authors included psychologists specialising in substance abuse prevention.

Stated expertise of program developers: The authors have experience in the development of Internet and DVD‐based health programs.

Process of development and testing: The SmartRx program is based on the Cook and Youngblood conceptual model guiding the development of workplace substance use and misuse prevention interventions. The multimedia approach "was designed to make the program more appealing and engaging". No further information was reported regarding development or testing.

Availability: Access to the program was provided on request by the study authors.

Purpose: To prevent the misuse of psychoactive prescription medications.

Content: Information about five classes of medications: analgesics, sedative‐hypnotics, stimulants, antidepressants and tranquillisers. The program consists of three sections. 1. Medication facts ‐ providing information about the pharmaceutical properties of medications including therapeutic action, potential side effects and recommended guidelines for self‐administration. 2. Smart treatment use ‐ instructs users on the safe administration and responsible use of medications. It contains information on drug tolerance, abuse and dependence and information, how to determine if they need help and what to do if they think they have a problem. 3. Managing your health ‐ focuses on alternatives to medications and suggestions on ways to improve health including exercise, relaxation and yoga.

Relationship between developer and user: Health professionals to patients.

Target audience: Women who are currently using or anticipate the use of medications with abuse potential.

Format: Web‐based multimedia program

Hardware required: Computer with Internet access.

Media: Text, graphics, animations, video and audio

Delivery: Participants accessed the program over the Internet.

Length of program: The program consisted of 110 pages. The length of the program varies depending on what sections the user accesses. The length of time that participants used the program was recorded with results showing 8% used it for less than 20 minutes, 32% for 20 minutes to one hour, 28.5% one to two hours and 31.5% over tow hours. Average utilisation was one hour and 53 minutes.

Number of times program was used: The number of times participants logged into the program was recorded with results showing that seven participants did not use the program. Of those that did 12% accessed the program on one occasion, 24% on two occasions, 32.5% on three to four occasions, 18.5% on five to six occasions and 13% on seven or more occasions.

Time point of delivery: Participants were considered to be at risk of pharmaceutical misuse due to their profession. However, they were not necessarily taking any of the medications targeted by the program.

Success at reaching target audience: Seven participants in the multimedia group did not use the program.

Assistance: None

Interactivity: Limited ‐ Fully. Participants are able to navigate through the program and choose the information components that they want to access and the order in which they access them. However there are fully interactive segments within the program where users are able to complete self‐assessments to determine if they need help with their use of prescription medication and evaluate their fitness level.

Tailoring: Yes. The program contained self‐assessments on current or anticipated prescription drug use and self‐reported learning interests. Assessment results were used to recommend sections of the program that were most applicable to the user.

Source of information about comparators: Information provided by the author in the published study

Description of comparator: Waiting list controls who did not receive any education.

Generic structure: The content included seven moves: Background on drug; Summary of use; Dosage instructions; Account of side effects; Constraints on patient behaviour; Outline of benefits and Clinical contact availability.

Rhetorical elements: There rhetorical elements in the program included are to inform, instruct and define. Terminology used to describe medications and their actions was defined for each of the medication classes. Instructions are clear and consistently identify whose role it is to perform the task.

Tenor: The tenor in the program is medical expert/health professional to patient. However, this is implied as the presenter in the program does not introduce themselves and provides no information regarding their background or qualifications. The presenter refers to themselves as "we" e.g. "we recommend that you..." but does not identify who this refers to. In the "Smart Use" section there is video of women discussing their medication with their health professional but the tenor remains the same.

Metadiscourse: The introduction to the program clearly states the purpose of the program before outlining the different sections and how they can be used. It also instructs users on how to navigate through the program and access further information.

Headings: Each section has a heading and a series of subheadings. Section headings are also listed in a panel to the left of the main screen and can be used to navigate through the program.

Technicality of language: Medical terminology was used but it was accompanied by a definition or explanation.

Lexical density: Overall lexical density was not calculated due to the variation in content. Lexical density was calculated from three segments of the "Medication facts" section. The introduction which provided background information about the medications had lexical density of 51%. A segment providing specific information about one of the classes of medication had lexical density of 65% and a video of a conversation between a patient and a doctor had lexical density of 31%.

Factual content: The program did not state the source of the information or the date it was produced.

Format: The program is divided into three main sections. 1. The Medication Facts section provides a description of how medications work and common concerns presented with graphics and animation. The"concerns" section contains a list of commonly asked questions with video segments of pharmacists answering each question. 2. The Smart Use section "contains information about drug tolerance, abuse and dependence and the warning signs of each. Real‐life video testimonials are provided of women who have experienced problems with prescription medications and there is a self‐assessment on how to determine if one needs help with one's use of prescription medication". 3. The Managing Your Health section presents alternatives to medications with interactive segments on evaluating one's fitness level and tips for starting an exercise regime as well as printable pages listing particular exercises.

Evaluation of comparator:

Not applicable

Goodyer 2006

Source of information about intervention: Information provided by the authors in the published study and a copy of the voice‐over script for the English version of the program.

Description of intervention: Multimedia program demonstrating metered dose inhaler technique. This study used the Turkish version of the program used in Savage 2003.

Name of program: Multimedia Touch Screen System (MTS)

Country of origin: England

Language: Turkish (however the program is available in other languages including English)

Year program used in the study was produced: Not reported

Stated expertise of content developers: Pharmacy Practice Group King's College London.

Stated expertise of program developers: Not reported

Process of development and testing: Not reported other than to state that the content was based on that of the "how to use your inhaler" section of the Ventolin PIL.

Availability: No longer available.

Purpose: To demonstrate correct inhaler technique to Turkish patients with asthma

Content: The program covered eight information points relating to correct inhaler technique and additional information about posture. It consisted of video clip demonstrations of correct inhaler technique with a voice‐over explanation.

Relationship between developer and user: Health professionals to patients.

Target audience: Turkish asthma patients with poor English skills

Format: Computer‐based multimedia touch‐screen system

Hardware required: Computer with touch‐screen

Media: Video and audio

Delivery: Viewed on a computer in the patient's home

Length of program: Not reported

Number of times program was used: Patients only used the program on one occasion but were allowed to use it for as long as they wished

Time point of delivery: Patients were longstanding inhaler users (mean years (SD) = 8.8 (8.9)

Success at reaching target audience: Assessors went to the patients' homes, administered the program and conducted assessments on one visit therefore all participants in the intervention arm viewed the program.

Assistance: The authors state that patients required "little instruction on use of the system" but do not describe this further

Interactivity: Limited. Users could interact with the program using a touch‐screen that allowed them to navigate through the program.

Tailoring: No

Source of information about comparators: Information provided by the authors in the published study. The evaluation of the PIL used the current version of the Ventolin PIL produced by Allen and Hanbury (dated June 2009).

Description of comparators:

1. Patient information leaflet (PIL)

A translated (into Turkish) patient information leaflet. The leaflet was produced by a study author and was an exact translation of the current PIL produced by the drug manufacturer (Allen and Hanbury) for Ventolin MDI.

2. Verbal support

Written information was followed by verbal support from a translator who identified areas where the patient's technique could be improved and then spent up to 15 minutes discussing this with the patient.

Evaluation of intervention:

Generic structure: The program focused on the information contained in the "How to use your inhaler" section of the PIL. It therefore only contained the "Dosage instructions" move.

Rhetorical elements: The program consisted almost entirely of instructions. The instructions used the imperative form and responsibility for the actions was clear. The importance and urgency of actions was clearly stated.

Tenor: Unable to assess

Metadiscourse: The purpose of the program was clearly stated at the beginning.

Headings: Unable to assess

Technicality of language: Lay language was used with minimal medical terminology.

Lexical density: 42%. Calculated from the script for the program voice‐over.

Factual content: Unable to assess

Format: A touch screen multimedia program in which a white male model demonstrates the steps required for correct MDI use accompanied by a voiceover. Key points from the voiceover were reinforced as on‐screen text. Users could choose to replay steps.

Evaluation of comparator: Ventolin PIL

Generic structure: The leaflet was divided into six sections: 1. What ventolin is and what it is used for; 2. Before you use ventolin; 3. How to use you inhaler (ventolin); 4. Possible side effects; 5. How to store ventolin and 6. Further information. All of the possible moves other than "Information regarding monitoring" were identifiable. The sequence of moves was typical for PILs.

Rhetorical elements: The predominant rhetorical elements in the leaflet were to inform and instruct. Instructions used the imperative form and responsibility for the actions was clear. The importance and urgency of actions was clearly stated.

Tenor: The leaflet was written by the drug manufacturer for patients using ventolin. The intended reader was clearly identified at the beginning of the leaflet ("Information for the user") and the relationship was clear and consistent throughout. The identity of the writer was not explicitly stated but implied by the drug company logo and copyright at the end of the leaflet.

Metadiscourse: The purpose of the leaflet was stated as providing information about ventolin for the user. The sections contained in the leaflet were also listed at the beginning.

Headings: Headings were present, clearly formatted and clearly signposted the information contained in each section.

Technicality of language: There was minimal use of medical terminology and where it was used its meaning was explained. Risk was explained using words (e.g. common, uncommon) and numeric (e.g. less than one in 10) descriptors.

Lexical density: 46%. The lexical density was calculated from the "how to use your inhaler" section of the leaflet.

Factual content: The source and evidence base for the information contained in the leaflet was not stated. However, the leaflet included the date it was created/updated.

Format: The leaflet was a double sided A4 page that contained a mix of prose and bullet point and numbered lists. It used a font size smaller than 12‐point but provided contact information for accessing a large print version of the leaflet. It contained a shaded box providing instructions on the use of an MDI broken into nine steps and accompanied by photographs of a person performing six of the steps.

Inadequate information was provided on which to base an assessment of the verbal support provided.

Kato 2008

Source of information about intervention: Information provided by the authors in the published study and information from the re‐mission website including the game manual, screen shots and short video excerpts from the game.

Description of intervention:

Name of program: Re‐Mission

Country of origin: USA

Language: English, Spanish and French

Year program used in the study was produced: 2006

Stated expertise of content developers: Scientific and medical consultants contributed to the content of the game.

Stated expertise of program developers: Video game developers and animators were involved in the construction of the video game.

Process of development and testing: Developed by the study authors. Behavioural objectives identified from literature reviews and pre‐production studies were translated into game structure on the basis of principles from the self‐regulation model of health and illness. "Teens and young adults with cancer participated actively throughout the game development process to ensure that the game was fun, and that it really spoke to the issues that they confront every day in their fight against cancer."

Availability: A trailer of the game can be viewed on the website www.re‐mission.net and the game can be ordered in CD or DVD format from the website. It is available free of charge.

Purpose: To improve health‐related behaviours such as treatment adherence, cancer‐related self‐efficacy and knowledge in adolescents and young adults with malignancies.

Content: The game does not provide any structured information, but the game play includes destroying cancer cells and managing common treatment related effects such as bacterial infections, nausea and constipation by taking appropriate medications and engaging in positive self‐care behaviours.

Tenor: Developed by health professionals for patients.

Target audience: Adolescents and young adults with a diagnosis of a malignancy.

Format: Video game for personal computer

Hardware required: Computer

Media: Text, audio and animation.

Delivery: Played on computers supplied to the patients in the patient's own home.

Length of program: The game's length is variable depending on how the patient plays it. There are 20 levels and the patient must complete the mission successfully before moving on to the next level.

Number of times program was used: Patients were asked to play the video game for at least one hour per week for a three month period. However, only 33% of the intervention group (and 22% of the control group) used the game for the requested period of time.

Time point of delivery: Patients had been diagnosed with cancer and commenced their treatment regimes.

Success at reaching target audience: 13% of the intervention group did not use their computer or attempt to play the game at all (compared with 9% of the control group).

Assistance: None

Interactivity: Fully interactive

Tailoring: No

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

A commercial PC game (Indiana Jones and the Emperor's Tomb) was used as it had similarities with the "play structure and controller interface" of Re‐Mission.

Evaluation of intervention:

Generic structure: From the information available, the game contains at least four moves: Summary of use; Account of side effects; Constraints on patient behaviour and Outline of benefits.

Rhetorical elements: Users are given audio instructions and suggestions throughout the mission. The main rhetorical elements in the game are to inform and instruct.

Tenor: Health professional to patient. The mission briefing is given by a doctor who outlines the assignment.

Metadiscourse: At the beginning of each mission users are provided with a briefing of their assignment and a list of objectives that they need to complete in order to be successful in the mission.

Headings: The game does not contain headings but uses a "heads up display (HUD)" as a signpost throughout the game. The HUD includes radar that identifies the position of the user and navigational arrows to guide the user through the mission.

Technicality of language: Medical terminology is used but defined.

Lexical density: Unable to assess

Factual content: The source of the content is identified in the program information. This contains disclaimers stating that the content is for informational purposes only and does not take the place of medical advice and that the publisher "makes reasonable efforts to include accurate and current information whenever possible, but makes no warranties as to its accuracy or completeness". The date the program was produced is shown in the copyright.

Format: A fully interactive game which is available on CD, DVD and as a download (Windows only) from the Internet. The game contains 20 missions each presenting a clinical scenario of a patient with a particular type of cancer who is facing particular treatment related issues. At the beginning of each mission, the user is provided with a brief medical history of the patient as well as a list of objectives for their mission. The user then navigates through the mission in order to complete these objectives e.g. use antibiotics to blast bacteria which are causing infection following a course of chemotherapy.

Evaluation of comparator:

Not applicable

Kinnane 2008

Source of information about intervention: Information provided by the authors in the published study as well as a copy of the DVD.

Description of intervention: Video about chemotherapy, its side effects and how to prevent and manage these side effects given as well as standard pre‐chemotherapy education.

Name of program: Staying well during chemotherapy

Country of origin: Australia

Language: The video is available in 12 languages. Only the English version was used for this study

Year program used in the study was produced: 2005

Stated expertise of content developers: Developed by oncology nursing staff from the Southern Health chemotherapy unit with input from The Cancer Council Victoria, Cancer Nurses Society of Australia and Southern Health Oncology and Medical Haematology Focus Group.

Stated expertise of program developers: Video was filmed and produced by LOTE Marketing

Process of development and testing: No information was provided other than that the video was developed by oncology nurses with input from the organisations listed above.

Availability: Not reported

Purpose: To improve patient safety when at home while they are undergoing chemotherapy treatment and to help them better understand the effects of treatments and assist in the management of side effects

Content: Generic information about chemotherapy and how to manage side effects.The video outlines the most important take home information on dealing with nausea and vomiting, taking anti‐emetics, monitoring for and reporting signs of infection, low platelet count and anaemia, mouth care, advice concerning eating well and drinking fluids, prevention and control of constipation and diarrhoea.

Target audience: Patients about to start chemotherapy

Format: DVD

Hardware required: Television and DVD player

Media: Video with audio voice‐over

Delivery: Patients watched the video, with family members who were present on the day, in a separate room of the treatment centre

Length of program: 10 minutes and 30 seconds

Number of times program was used: Once

Time point of delivery: Prior to starting chemotherapy

Success at reaching target audience: All participants viewed the computer program on site at the treatment centre

Assistance: No medical or nursing staff were present during the video.

Interactivity: No

Tailoring: No

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

Standard care

Standard pre‐chemotherapy education consisting of a one hour education session with a member of the nursing staff and written information.

The nurse explained how the chemotherapy drugs work, side effects, self‐help concepts including dietary and fluid intake advice, special instructions regarding mouth care, how and when to take antiemetics, monitoring for problems associated with low blood counts and advice regarding the prevention and control of diarrhoea and constipation.

Written information included a Neutropenic Alert card detailing contact numbers and information for healthcare professionals to use if the patient presented unwell, details of the chemotherapy regime, side effects and their management, self‐help concepts and circumstances in which the patient should contact the treatment centre.

Evaluation of intervention:

Generic structure: There are five moves contained within the video: Summary of use; Account of side effects; Information regarding monitoring; Constraints on patient behaviour and Clinical contact availability.

Rhetorical elements: The main rhetorical elements in the video are to inform and instruct. Instructions are clear and consistently identify whose role it is to perform the task.

Tenor: The health professional to patient relationship is not stated explicitly but is implied by the language e.g. "during our care for you".

Metadiscourse: The purpose of the video is stated in the introduction which also outlines the main topics of information that will be presented.

Headings: None

Technicality of language: Medical terminology was largely avoided. However, where it was used, it was accompanied by an explanation.

Lexical density: 51%. Calculated from the first three minutes of the video.

Factual content: The source of the content and the date it was last updated is implied by the date and acknowledgement of the Southern Health department of medical oncology and clinical haematology on the DVD.

Format: Although the program is produced using DVD format, this only became evident when a copy of the program was obtained. The program is described by the study authors as a video and does not use any of the functionality of the DVD format. It is designed to be viewed as a video, from beginning to end, with no section breaks or menu to allow navigation. It consists of video images, and one short animation, illustrating information provided by a voiceover with background music.

Evaluation of comparators:

Generic structure: Based on the information provided by the authors the content included at least five moves: Summary of use; Account of side effects; Information regarding monitoring; Constraints on patient behaviour and Clinical contact availability.

Rhetorical elements: Unable to assess

Tenor: Nurse to patient

Metadiscourse: Unable to assess

Headings: Unable to assess

Technicality of language: Unable to assess

Lexical density: Unable to assess

Factual content: Unable to assess

Format: One‐hour standardised education session given by a nurse and written information including a Neutropenic Alert card

Knoerl 1999

Source of information about intervention: Information provided by the authors in the published study.

Description of intervention: Instructional video about the use of PCA

Name of program: Not reported

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Not reported

Stated expertise of program developers: Not reported

Process of development and testing: Not reported

Relationship between developers and users: Not reported

Availability: Not reported

Purpose: To provide preoperative teaching regarding the use of PCA therapy that increases patient knowledge about PCA and corrects mistaken beliefs about pain medicine.

Content: Not reported

Target audience: Patients undergoing a surgical procedure who are expected to use PCA postoperatively.

Format: Videotape

Hardware required: Television and VCR

Media: Video with audio

Delivery: The video was viewed in the Ambulatory Surgical Unit prior to the patients going to theatre.

Length of program: 11 minutes

Number of times program was used: Once

Time point of delivery: Patients viewed the video preoperatively and started PCA in the immediate postoperative period.

Success at reaching target audience: All participants viewed the presentation on site.

Assistance: Not reported

Interactivity: No

Tailoring: No

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

Usual care: informal teaching provided by hospital medical staff about PCA as part of usual perioperative care.

Evaluation of intervention:

Inadequate information was provided on which to base an assessment

Evaluation of comparator:

Not applicable

Lirsac 1991

Source of information about intervention: Information provided by the authors in the published study.

Description of intervention: Video about the use of MDIs

Name of program: Not reported

Country of origin: France

Language: French

Year program used in the study was produced: Not reported

Stated expertise of content developers: Not reported

Stated expertise of program developers: Not reported

Process of development and testing: Not reported

Relationship between developers and users: Not reported

Availability: Not reported

Purpose: To demonstrate correct use of MDIs.

Content: Described the use of MDIs

Target audience: Patients prescribed MDIs.

Format: Videotape

Hardware required: Television and VCR

Media: Video with audio

Delivery: Not reported. However, the article implied that the video was viewed on site.

Length of program: Five minutes

Number of times program was used: Once

Time point of delivery: Patients were regular users of MDIs prior to viewing the video.

Success at reaching target audience: All participants viewed the presentation on site.

Assistance: Not reported

Interactivity: No

Tailoring: No

Source of information about comparators: Information provided by the authors in the published study.

Description of comparator: Instruction sheet read by a doctor while participants looked at pictorial representations. Education lasted three to four minutes.

Evaluation of intervention:

Inadequate information was provided on which to base an assessment

Evaluation of comparators:

Inadequate information was provided on which to base an assessment

Mazor 2007

Source of information about intervention: Copy of the videotape as well as information provided by the authors in the published study.

Description of intervention: Video showing a physician‐patient encounter about oral anticoagulant medication management.

Name of program: Patients' views about anti‐coagulation therapy: A research study

Country of origin: USA

Language: English

Year program used in the study was produced: 2005

Stated expertise of content developers: Health professionals

Stated expertise of program developers: Not reported

Process of development and testing: The videos were produced by the authors for this study. Draft scripts were created and reviewed by the authors before being filmed. Draft versions of the videos were pilot tested with four patients attending the anticoagulant clinic. Final versions of the scripts were reviewed by the two physician authors for clinical accuracy.

Relationship between developers and users: Health professional to patient

Availability: Not reported

Purpose: To educate patients on anticoagulant medication using different methods (narrative evidence, statistical evidence or both) to communicate evidence to patients.

Content: The videos depicted a physician talking to a patient about anticoagulant medication management. The physician covered issues such as dosing, target INR's and symptoms indicating side effects of the medication. There were three versions of the video presenting evidence using narrative (patient anecdotes), statistical or a combination of both methods.

Target audience: Patients taking anticoagulant medications.

Format: Videotape

Hardware required: Television and VCR

Media: Video with audio

Delivery: Video was watched in the participant's home.

Length of program: Not reported

Number of times program was used: Patients were asked to view the video once, but were free to watch it as many times as they liked.

Time point of delivery: Patients had been prescribed warfarin and receiving care at an anticoagulation clinic for at least three months.

Success at reaching target audience: It is unknown how many participants viewed the videos, but questionnaires were returned by fewer patients in the intervention than the control groups and 44/350 patients from the intervention groups reported that they were unable to watch the video as they did not have access to a VCR.

Assistance: None

Interactivity: No

Tailoring: No

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

Usual care: participants did not receive a video or other form of education as part of this study.

Evaluation of intervention:

Generic structure: The content of the video contained seven moves. The three moves not included were contraindications, outline of benefits and storage instructions.

Rhetorical elements: The majority of the video's content informed users about warfarin and its use.

Tenor: The video consists of a conversation between a doctor and patient. The person viewing the video is instructed to imagine that the doctor in the video is talking to them.

Metadiscourse: Patients are told that they are about to see a video of a doctor and patient talking about warfarin. However, the purpose of the video is not presented.

Headings: None

Technicality of language: Medical terminology was avoided or used with accompanying explanations

Lexical density: 43%. Calculated from the script for the video.

Factual content: The year that the video was produced was shown as part of the copyright on a label on the videocassette. The statistical evidence version of the video stated that certain information was based on research findings. However, the source of the evidence is not given. The narrative version illustrated the same information using patient anecdotes.

Format: Videotaped conversation between a doctor and patient

Evaluation of comparators:

Not applicable.

McElnay 1989

Source of information about intervention: Information provided by the authors in the published study.

Description of intervention: Video about the use of MDIs

Name of program: Not reported

Country of origin: UK

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: The video was developed by the study authors who were health professionals.

Stated expertise of program developers: The Audio‐Visual Unit at The Queen's University of Belfast.

Process of development and testing: A short video was prepared on the correct use of the metered dose inhaler. The adequacy of the film was assessed in a pilot study involving 30 students studying non‐medical subjects. Based on the results obtained, a second improved video film was prepared for use in the study.

Relationship between developers and users: Developed by health professional for patients

Availability: Not reported

Purpose: To demonstrate the correct use of the metered dose bronchodilator inhaler.

Content: The correct use of a metered dose inhaler illustrating six steps 1. Shake the inhaler and remove the cap. 2. Hold the inhaler upright. 3. Breathe out fully through your mouth, emptying as much air from your lungs as possible. 4. Close lips tightly around the mouthpiece. 5. Press the canister as you start to take a long deep breath‐in through your mouth. 6. Close mouth and hold breath for five to ten seconds before slowly breathing out.

Target audience: Adults who have been prescribed a metered dose inhaler.

Format: Videotape

Hardware required: Television and VCR

Media: Video with audio

Delivery: The video was viewed on site.

Length of program: Five minutes

Number of times program was used: Once

Time point of delivery: The participants in this study were healthy volunteers who had no previous experience in the use of MDIs

Success at reaching target audience: All participants viewed the video on site.

Assistance: Not reported

Interactivity: No

Tailoring: No

Description of comparators:

1. Ventolin PIL

Written instruction consisting of the drug manufacturer's (Allen & Hanbury) PIL for Ventolin.

2. Personal instruction

Personal instruction consisted of a five minute demonstration of correct inhaler technique by a pharmacist, review of a custom‐designed instruction sheet outlining the six steps required for using a MDI correctly and the Ventolin PIL.

Evaluation of intervention:

Generic structure: The program illustrated six steps involved in correct MDI use. It therefore only contained the "Dosage instructions" move.

Rhetorical elements: Unable to assess

Tenor: Unable to assess

Metadiscourse: Unable to assess

Headings: Unable to assess

Technicality of language: Unable to assess

Lexical density: Unable to assess

Factual content: Unable to assess

Format: A short five minute video demonstrating correct MDI use.

Evaluation of comparators:

Evaluation of the PIL presented in Goodyer 2006.

Inadequate information was provided on which to base an assessment of the personal instruction provided.

Navarre 2007

Source of information about intervention: The current version of the tutorial available online as well as information provided by the authors in the published study.

Description of intervention:

Name of program: Metered Dose Inhalers

Country of origin: USA

Language: English

Year program used in the study was produced: 2000

Stated expertise of content developers: Faculty at the University of Michigan College of Pharmacy.

Stated expertise of program developers: Developed with the assistance of the University of Michigan Center for Information Technology. Website design and art direction by Steve Burdick, University of Michigan ITCS Web and Database Services.

Process of development and testing: Not reported

Relationship between developers and users: Health professional to patient

Availability: The tutorial was also created for access through a website and information regarding the website is available from Dr Erickson at the University of Michigan

Purpose: To demonstrate the correct use of MDIs

Content: The tutorial covers the steps of inhaler technique

Target audience: Adults using MDIs

Format: Computer program available over the Internet or on CD‐ROM.

Hardware required: Computer

Media: Text, video of an actor‐patient and animation

Delivery: Viewed on computers on site at either the clinic or pharmacy.

Length of program: Not reported

Number of times program was used: Once

Time point of delivery: At least six months after commencing inhaler.

Success at reaching target audience: All participants viewed program on site.

Assistance: The research assistant oriented the patient on the use of the computer and was available to answer any question regarding navigation through the program.

Interactivity: Not reported

Tailoring: Not reported

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

Usual care: the participants did not receive any education as part of this study.

Evaluation of intervention:

Generic structure: 15 steps outlining the correct use of an MDI. The content is limited to the "Dosage instructions" move.

Rhetorical elements: The program provides instructions but also informs users of why the action is important and the consequences of performing the action incorrectly.

Tenor: The organisation and individuals who created the program were identified in a heading at the top of the page and in a separate "credits" page. The user was clearly responsible for each of the actions presented.

Metadiscourse: There is no information provided regarding the purpose of the program other than the title stating that it is part of the inhaler instructional series.

Headings: Each step is shown with a heading. Selecting the heading then takes you to another page where information about that step is presented

Technicality of language: The acronym MDI was used without accompanying explanation. Some technical and medical language was also used without explanation e.g. propellant, aerosol impaction, tachycardia.

Lexical density: 45%. Calculated from the first two sections, containing nine of the 15 steps.

Factual content: The authors of the program were identified and the year in which the program was developed was presented as part of the copyright.

Format: The tutorial is divided into six sections containing a total of 15 steps which are presented in a summary page. When the link for each step is selected a page presenting written instructions is shown with an accompanying window in which a short audiovisual presentation can be played. This consists of a video of an "actor‐patient" performing that step, some supporting animations and a voiceover reading the written instructions. Users can navigate through the steps using "next" and "back" arrows or can select individual steps from links on the summary page.

Evaluation of comparators:

Not applicable.

Neafsey 2002

Source of information about intervention: Information provided by the authors in the published study and in a previous publication describing the development and testing of the program (Strickler 2002).

Description of intervention: Computer program about the interaction between prescription medications and over‐the‐counter medications and alcohol.

Name of program: Preventing Medicine Conflicts

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Pharmacologist, visual communications designer and design students

Stated expertise of program developers: Animations were produced by a professional visual communications designer using Adobe Illustrator and Aftereffects.

Process of development and testing: The program was designed based on evidence on the learning styles of older adults. Patients in focus groups evaluated aspects of the program including visual features, language used in the text and the interactive questions on multiple occasions as the program was being developed leading to changes in the program. It was revised again following pilot testing with 60 older adults (Neafsey 2001).

Relationship between developers and users: Developed by health professionals for patients

Availability: The program can be purchased from the University of Connecticut School of Nursing

Purpose: To teach older adults about potential drug interactions that can results from self‐medication with over‐the‐counter agents and alcohol

Content: Information about potential interactions between prescribed medications with over‐the‐counter medications and alcohol.

Target audience: Older adults (aged 60 or over) living independently in the community

Format: CD‐ROM using Macromedia Authorware software

Hardware required: Notebook computers with infra‐red touch‐screen

Media: Text, still graphics and animations (no audio).

Delivery: Viewed on computers provided at the participating senior centre clinics

Length of program: 80 minutes

Number of times program was used: Once

Time point of delivery: Participants were already taking prescription medications in conjunction with OTC preparations.

Success at reaching target audience: All participants viewed the computer program on site

Assistance: Not reported

Interactivity: Limited: There are questions with multiple choice answers throughout the program. Users are able to use buttons on the touch‐screen to answer questions and control the animations. Users can also skip questions. Feedback is given based on the response to each question.

Tailoring: None

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

1. Written information

The written information group received an information booklet containing the same information as the computer program but presented using only text. The text is set at 14 point Arial typeface and is written at a 6th grade reading level.

2. No information

The control group did not receive any education as part of this study.

Evaluation of intervention:

Generic structure: The focus of the program is the interaction between prescription medications and over‐the‐counter medications and alcohols. This is contained within the "constraints on patient behaviour" move. Unable to assess whether information from other moves was also included in the program.

Rhetorical elements: Unable to assess

Tenor: Unable to assess

Metadiscourse: Unable to assess

Headings: Headings are used in the program. The information hierarchy and placement of elements on the page were tested with participants during development of the program.

Technicality of language: The authors stated that the health information within the program was at Fleish‐Kincaid grade 5 reading level. Particular vocabulary and descriptions within the program were tested in focus groups to identify and change vocabulary that the target population found difficult to understand.

Lexical density: Unable to assess.

Factual content: Unable to assess

Format: Computer with touch screen allowing on screen buttons for navigation ("menu", "back" and "next") and for control of animations ("replay", "pause", "play"). Program content is divided into four main sections: blood pressure medicines, blood thinners, antacids and acid reducers and pain relievers. The font used for the text was 18 to 20 point Stone Sans Bold with 28 and 32 point font size used for headings. Text line lengths were typically between two to four words in length and the longest block of continuous text was five lines.

Evaluation of comparators:

Inadequate information was provided on which to base an assessment

Neafsey 2001

Name of program: This is an earlier version of the "Preventing Medicine Conflicts" interactive computer program (Neafsey 2002). Description and evaluation of the intervention are the same as those in Neafsey 2002.

Source of information about comparators: Information provided by the authors in the published study.

Description of comparators:

The control group did not receive any education as part of this study.

Olver 2009

Source of information about intervention: Copy of the CD‐ROM and information provided by the authors in the published study.

Description of intervention: CD‐ROM

Name of program: Understanding cancer

Country of origin: Australia

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Health professionals including oncologists and psychologists

Stated expertise of program developers: The CD‐ROM was developed with media producers Steve Whitham Media and M‐Plex Multimedia

Process of development and testing: The CD‐ROM was designed using the "medical expertise of the researchers in association with local media expertise".

Relationship between developers and users: Developed by health professionals for patients.

Availability: Not reported

Purpose: To provide chemotherapy treatment information as part of the informed consent process

Content: The authors state that the CD‐ROM contains the same information about chemotherapy as their standard written information and consent sheet but do not outline what information this contains. The CD‐ROM also has additional information about cancer and its treatment under the headings of type of cancer, nutrition, patient's perspective, further information, prevention, help, frequently asked questions, glossary of terms and consent form.

Target audience: Adults who are about to start chemotherapy

Format: CD‐ROM using Macromedia software

Hardware required: Computers

Media: Text, still graphics, video and audio

Delivery: Viewed on computers provided on site at the Chemotherapy Day Centre. Participants were also able to take the CD‐ROM home for further viewing.

Length of program: Depends on which sections of program the user chooses to view

Number of times program was used: Viewed on one occasion on site and then at the participant's discretion off site

Time point of delivery: Prior to starting chemotherapy

Success at reaching target audience: All participants viewed CD‐ROM on site, 36.2% viewed the CD‐ROM again at home

Assistance: A nurse was available on site to help with navigation if participants were unfamiliar with the technology

Interactivity: Limited. patients are able to view components of the program in their entirety or choose particular areas that they are interested in viewing.

Tailoring: Yes ‐ patients can select from a menu the type of cancer they have been diagnosed with. They are then presented with information specific to that cancer and its treatment.

Source of information about comparators: Information provided by the authors in the published study.

Description of comparators:

Written information consisting of the hospital's standard information sheet and consent form.

All patients (intervention and control) were also provided with usual care consisting of verbal information about their chemotherapy by the medical or nursing staff. They were free to ask questions and access other information.

Evaluation of intervention:

Generic structure: All of the moves except for "Dosage instructions", "Contraindications" and "Storage instructions" were included in the program.

Rhetorical elements: Most of the information is presented to inform and instruct the user. However, there is lack of clarity at times as to whether the information is being presented to instruct or inform and whose responsibility it is to perform the action.

Tenor: For most of the components of the program the tenor is health professional to patient. This is stated in the introduction where the doctor and the cancer centre are identified. The user is referred to using both impersonal (the patient) and personal (you) language in the program. The program also contains videotaped interviews with patients providing their perspective on their diagnosis and treatment. For this component, the tenor is patient to patient.

Headings: Headings are used consistently throughout the program and are used to aid navigation.

Technicality of language: The information contains frequent use of medical terminology. The definition for some but not all of this terminology can be obtained by selecting the relevant word if it is highlighted or via the "Glossary of terms" section.

Lexical density: Overall lexical density could not be calculated due to the variation in content. Information about the cancer and chemotherapy, presented with text and voice‐over, in the "Type of cancer" section had lexical density of 56%. A video of a health professional providing information about nutrition had lexical density of 49% and a video of a patient describing their experience of cancer and its treatment had lexical density of 29%.

Factual content: The source of the information was identified as the Royal Adelaide Hospital Cancer Centre. Although there was no date showing when the program was last updated, patients were advised that they could use the program to link to up to date information on the Internet.

Format: CD‐ROM with the main content headings presented in a menu on the left. These include: Type of cancer; Nutrition; FAQs, Patient's perspective; Prevention; Glossary of terms; Further information; Help and Consent form. Selecting some headings leads to a menu of subheadings and information presented as text, voice‐over which reads the text and accompanying animations. Users can navigate through this information using "previous" and "next" arrows at the bottom of the screen. Words highlighted in blue can be linked to in order to access further information. Selection of other headings leads to videos of health professionals or patients. Users can pause and rewind these videos.

Evaluation of comparators:

Inadequate information was provided on which to base an assessment

Osguthorpe 1983

Source of information about intervention: Information provided by the authors in the published study.

Description of intervention: Video about medications used to treat psychiatric illnesses

Name of program: Videotaped Nurse Explanation

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Script was developed by the study investigators (nurses)

Stated expertise of program developers: The hospital's audiovisual department

Process of development and testing: The script was developed by the investigators and the video produced in the hospital's audiovisual department. No testing was reported

Relationship between developer and user: Health professional to patient.

Availability: Not stated

Purpose: To provide patients with general information about study medications

Content: A videotaped nurse explanation providing general information (not specific to each medication) about 9 medications used for treatment of psychiatric illnesses. This included general information common to all of the medications such as their purpose, side effects, precautions and helpful hints.

Target audience: Psychiatric inpatients

Format: Videotape

Hardware required: Television and VCR

Media: Video, Audio, Text and Cartoons

Delivery: Viewed in a conference room on the hospital ward

Length of program: Eight minutes

Number of times program was used: Once

Time point of delivery: Patients had started the medication within 3 weeks before watching the video

Success at reaching target audience: All participants viewed the presentation on site.

Assistance: Not reported

Interactivity: No

Tailoring: No

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

Written information consisting of a drug information sheet containing the same information as the videotaped nurse explanation except that it identified the particular medication by name, picture and dosage.

Evaluation of intervention:

Generic structure: The authors stated that the video "was a general discussion and was not specific to each drug. The content followed the same outline as the drug information sheet. No new information was included". Although not specifically stated this implied that the video contained the same information as the "general information" section of the leaflet which covers four moves: Summary of use, Account of side effects, Constraints on patient behaviour and Clinical contact availability.

Rhetorical elements: Unable to assess

Tenor: Nurse to patient.

Metadiscourse: Unable to assess

Headings: Unable to assess

Technicality of language: Unable to assess

Lexical density: Unable to assess

Factual content: Unable to assess

Format: An eight minute video consisting of a nurse explanation interspersed with cartoons and printed materials to emphasise important points. Important points were also summarised at the end of the video.

Evaluation of comparators: Drug information sheet

Generic structure: The authors described the content of the information sheet as "Information was specific in identifying the particular medication by name, by picture and by dosage. General information described the purpose, side effects, precautions and helpful hints common to all of the medications included in the study. The drug information sheet ended with a place for the telephone number of the ward to be written in so the patient could telephone the ward if questions emerged". This suggests that the information contains 6 moves: Background on the drug, Summary of use, Dosage instructions, Account of side effects, Constraints on patient behaviour and Clinical contact availability.

Rhetorical elements: Unable to assess

Tenor: Unable to assess

Metadiscourse: Unable to assess

Headings: Unable to assess

Technicality of language: Materials were aimed at fifth grade reading level with important medical symptoms translated into layman's terms.

Lexical density: Unable to assess

Factual content: Unable to assess

Format: The information sheet was constructed so that it could be folded into billfold size and carried easily

Powell 1995

Source of information about intervention: Information provided by the authors in the published study.

Description of intervention:

Name of programs: Six videotapes: 1. "The Health Challenge: Managing Hypertension", 2. "Taking Lotensin", 3. "Taking Lopressor" 4. "Discussing menopause". 5. "Using Estraderm" and 6. "The Health Challenge: Managing High Cholesterol, Taking Zocor."

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Not reported

Stated expertise of program developers: "The videotapes were produced by a national medical media company."

Process of development and testing: Not reported

Availability: Not reported

Relationship between developers and users: Not reported

Purpose: To enhance compliance with prescribed drug therapy.

Content: Each video included "1) an explanation of the condition or disease process, 2) suggested changes in behaviour that can help ameliorate the problem and contribute to general wellness, 3) an explanation of how the prescribed drug works to control disease processes and symptoms, 4) a discussion of potential adverse effects and contraindications, 5) advice on the importance of compliance, including the need to refill the prescription as prescribed."

Target audience: Adults who have been prescribed benazepril, metoprolol, simvastatin or transdermal oestrogen.

Format: Videotape

Hardware required: Television and VCR

Media: Video with audio

Delivery: In the participant's home.

Length of program: Approximately 30 minutes.

Number of times program was used: Not recorded

Time point of delivery: Participants had already been prescribed the medications.

Success at reaching target audience: The numbers of participants that watched the videos is unknown. However a subset of participants were sent a questionnaire "to determine general reactions to the videotapes, the percentage of tapes actually received and the level of interest in this type of educational program." 205 questionnaires were sent out, of which 97 (47%) were returned. Of these 87% reported that they viewed the videotape.

Assistance: None

Interactivity: No

Tailoring: No

Source of information about comparators: Information provided by the authors in the published study.

Description of comparators:

The control group did not receive any education as part of this study.

Evaluation of intervention:

Generic structure: Based on the information provided by the authors the content included at least four moves: Summary of use; Account of side effects; Contraindications and Outline of benefits.

Rhetorical elements: Unable to assess

Tenor: Unable to assess

Metadiscourse: Unable to assess

Headings: Unable to assess

Technicality of language: Unable to assess

Lexical density: Unable to assess

Factual content: Unable to assess

Format: Videotapes of approximately 30 minute duration.

Evaluation of comparators:

No applicable.

Savage 2003

Source of information about intervention: Information provided by the authors in the published study and a copy of the voice‐over script for the English version of the program,

Description of intervention: Multimedia program about metered dose inhaler technique. This study used the English version of the program used in Goodyer 2006.

Name of program: Multimedia Touch Screen System (MTS)

Country of origin: England

Language: English (the program is also available in other languages).

Year program used in the study was produced: Not reported

Stated expertise of content developers: Pharmacy Practice Group King's College London.

Stated expertise of program developers: Not reported

Process of development and testing: Not reported other than to state that content was based on the "how to use your inhaler" section of the Ventolin PIL.

Relationship between developers and users: Health professionals to patients

Availability: No longer available

Purpose: To demonstrate correct inhaler technique

Content: The program covered the eight "key information points" on correct inhaler technique that are included in the Ventolin PIL provided by the drug manufacturer Allen & Hanburys.

Target audience: Adults using bronchodilator MDIs.

Format: Computer program

Hardware required: Multimedia touch screen computer

Media: Video, audio and text.

Delivery: Viewed on computers on‐site.

Length of program: Not reported

Number of times program was used: Once

Time point of delivery: Patients were longstanding users of bronchodilators

Success at reaching target audience: All participants viewed the program on site.

Assistance: Patients were supervised when viewing the program. The authors state that "using the touch screen was easy, with few people of any age required even minimal prompting"

Interactivity: Limited. Users interacted with the computer through a touch screen which allowed some control of navigation through the program

Tailoring: None

Source of information about comparator: Information provided by the authors in the published study. The evaluation of the PIL used the current version of the Ventolin PIL produced by Allen and Hanbury (dated June 2009).

Description of comparator:

Written instruction consisting of the drug manufacturer's (Allen & Hanbury) PIL for Ventolin.

Evaluation of intervention:

Evaluation of the multimedia program is presented in Goodyer 2006.

Evaluation of comparators:

Evaluation of the PIL is presented in Goodyer 2006.

Schnellinger 2010

Source of information about intervention: Information provided by the authors in the published study.

Description of intervention: Animated video about appropriate use of antibiotics.

Name of program: Not reported

Country of origin: USA

Language: English.

Year program used in the study was produced: Not reported

Stated expertise of content developers: Study researchers including paediatricians.

Stated expertise of program developers: Eight Point Productions was hired to produce and edit the video.

Process of development and testing: The script and characters were developed by the study authors. The video was reviewed at multiple points during its four month development by the authors and a group consisting of hospital administrators, health educators and the director of the Children's Office of Health Care Equity. The video was approved by the institutional review board prior to implementation.

Relationship between developers and users: Health professionals to patients

Availability: Not reported

Purpose: To educate parents about appropriate use of antibiotics.

Content: Information about the appropriate use of antibiotics.

Target audience: Parents

Format: Video

Hardware required: DVD player

Media: Video animations with audio

Delivery: Viewed on a portable DVD player in the emergency department.

Length of program: Three minutes

Number of times program was used: The video was viewed once with no opportunity to review it.

Time point of delivery: During presentation to the emergency department for acute care.

Assistance: Not reported

Interactivity: None

Tailoring: None

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

Written instruction consisting of the American Academy of Pediatrics pamphlet about antibiotic use and antibiotic resistance. Participants were able to read this pamphlet on one occasion for 15 minutes before returning it to the research assistant.

Evaluation of intervention:

Inadequate information was provided on which to base an assessment.

Evaluation of comparator:

Inadequate information was provided on which to base an assessment.

Schwarz 2008a

Source of information about intervention: Information provided by the authors in the published study and in response to request for specific information as well as a copy of the script.

Description of intervention: Computer program about emergency contraception (EC)

Name of program: EC Video Doctor

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Study author who is a specialist in women's reproductive health.

Stated expertise of program developers: Study authors oversaw the programming.

Process of development and testing: The program was pilot tested with women seeking urgent care until it was "bug free".

Relationship between developers and users: Health professionals to patients

Availability: Not reported

Purpose: To educate women of child‐bearing age about EC

Content: Covered nine key areas about EC: 1. What is EC, 2. When to use EC, 3. What to expect when you use EC, 4. Why to use EC, 5. How to use, 6. Where to get EC, 7. The cost of EC, 8. How does EC work 9. Why is EC important.

Target audience: Women of child‐bearing age.

Format: Computer program

Hardware required: Computer

Media: Short video segments, graphics and audio.

Delivery: In two separate Urgent Care Clinics where the women were attending appointments.

Length of program: 15 minutes

Number of times program was used: Once, with the participant having to use all parts of the program.

Time point of delivery: The program was shown to the participants after which they were given a sample pack of EC for them to use in the future if required.

Success at reaching target audience: All participants used the computer program on site

Assistance: Short introductory video instructed users on how to use the mouse to click on each of the nine questions.

Interactivity: Limited. Participants could select any of the nine section in any order but had to watch all of them before they could complete the program.

Tailoring: No

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

The control group viewed a computer program about preconception folate supplementation presented using the same format as the EC program.

Evaluation of intervention:

Generic structure: The content included six moves: Background,on drug; Summary of use; Dosage instructions; Account of side effects; Contraindications and Outline of benefits. The program also included information on how to access EC and its cost.

Rhetorical elements: The program primarily informs women about EC. The program included some instructions but presented them as statements using the passive voice which made their function unclear e.g. "The instructions included in the package suggest taking one pill as soon as possible, and a second pill 12 hours after the first one."

Tenor: A video doctor answered questions about EC that the user had selected. The doctor introduced themselves at the beginning of the program. In many instances, the language used was impersonal referring to "a woman" or "some women" rather than directly addressing the user.

Metadiscourse: The purpose of the program is stated in the introduction

Headings: Unable to assess

Technicality of language: The authors aimed for a seventh grade reading level and provided an audio voice‐over so that the program could be used in non‐literate populations.

Lexical density: 51%. Calculated from the script.

Factual content: Unable to assess

Format: Users select from nine questions each leading to short video segments during which the "video doctor" answers the question. The videos are accompanied by additional graphics and text where appropriate.

Evaluation of comparators:

The computer program was the same as that in the intervention arm except that it provided information about preconception folate instead of emergency contraception.

Self 1983

Source of information about intervention: Information provided by the authors in the published study.

Description of intervention: Video about MDI use

Name of program: Not reported

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Pharmacists and Medical Practitioners

Stated expertise of program developers: Technical assistance in videotape production was provided by two individuals from Memphis University School.

Process of development and testing: Not reported other than to state that the video was produced by the investigators.

Relationship between developers and users: Health professional to patient.

Availability: Not reported

Purpose: To demonstrate the correct use of inhalers.

Content: The video provided instructions based on ten steps for the correct use of an inhaler.

Target audience: Adults with an asthma diagnosis who use inhalers.

Format: Videotape

Hardware required: Television and VCR

Media: Video

Delivery: The video was viewed in an allergy clinic.

Length of program: Not reported

Number of times program was used: Once

Time point of delivery: 12/29 had previously used inhalers but had not seen a demonstration of proper technique. The others were starting an inhaler for the first time.

Success at reaching target audience: All participants viewed the presentation on site.

Assistance: Not reported

Interactivity: No

Tailoring: No

Source of information about comparators: Information provided by the authors in the published study.

Description of comparators:

1. Written information

An information sheet "reflecting the manufacturer's directions and the current literature".

2. Personal instruction

Personal instruction in the use of an inhaler by a pharmacist.

Evaluation of intervention:

Inadequate information was provided on which to base an assessment.

Evaluation of comparators:

Inadequate information was provided on which to base an assessment.

Solomon 1988

Source of information about intervention: Information provided by the authors in the published study.

Description of intervention: Video about tetracycline for treatment of STDs

Name of program: So they gave me these pills...

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Developed by the authors.

Stated expertise of program developers: Not reported

Process of development and testing: Video was developed by the authors.

Relationship between developer and user: Health and educational professionals to patients.

Availability: Copies of the video are available from the project officer at the Centre for Disease Control.

Purpose: To provide instructions on the correct administration of tetracycline for STD.

Content: The video provides basic information about tetracycline and the importance of correct administration. Step by step instructions are given for patients to build "an individualized schedule" for taking their medication.

Target audience: Patients diagnosed with a sexually transmitted disease requiring treatment with Tetracycline. The videotape was designed for patients of inner‐city clinics who are predominantly young, black and poorly educated.

Format: Videotape

Hardware required: Television and VCR

Media: Video and audio

Delivery: The video was viewed in the STD clinic.

Length of program: 10 minutes

Number of times program was used: Once

Time point of delivery: Patients viewed the video on the day they commenced their medication.

Success at reaching target audience: All participants viewed the video on site.

Assistance: The doctor observed the patient watching the video noting any difficulties the patient may have in devising their schedule. The patient was then seen by the doctor immediately after viewing the videotape. The doctor and patient review the schedule card together and answered any questions the patient had.

Interactivity: No

Tailoring: No

Source of information about comparators: Information provided by the authors in the published study.

Description of comparators:

Patients in both the intervention and control group were randomised to receive either special pill packaging or usual care:

1. Special pill packaging

Consisting of seven foil packed strips (one for each day of treatment) each with four individually wrapped pills. Each pill was labelled with the day, the number of the pill and instructions relating to when to take the pill and how long to wait until eating.

2. Usual care (verbal instructions)

Received a standard set of instructions provided verbally by the treating doctor to all study participants. The instructions consisted of the doctor reading out a paragraph which included the name of the medication, instructions on when and how to take the medication and how long to wait before resuming sexual activity.

Evaluation of intervention:

Generic structure: Based on the information provided by the authors the content of the video focuses primarily on the move "Dosage instructions" but also contains the moves "Summary of use" and "Constraints on patient behaviour".

Rhetorical elements: The video primarily instructs patients on the correct use of tetracycline as well as informing them of the consequences of improper use.

Tenor: Doctor to patient "a physician/narrator speaks directly to patients" and also patient to patient "testimonials from a young couple" who have taken the medication

Metadiscourse: Unable to assess

Headings: Unable to assess

Technicality of language: The physician/narrator "uses easy to understand language and concrete illustrations"

Lexical density: Unable to assess

Factual content: Unable to assess

Format: A 10 minute video of a physician narrator speaking directly to patients juxtaposed with testimonials from a young couple who explain what happened when they inadvertently took the medication incorrectly.

Evaluation of comparator: Verbal instructions given in the usual care group.

Generic structure: Consists of nine short sentences which contained only two of the possible 10 moves ‐ Dosage instructions and Constraints on patient behaviour. The instructions did not contain one of the two "obligatory moves" ‐ Account of side effects.

Rhetorical elements: Seven of the nine sentences instruct the patient while the other two inform. Instructions used the imperative form and responsibility for the actions was clear.

Tenor: Doctor to patient.

Metadiscourse: None.

Headings: Not applicable.

Technicality of language: Language does not contain any technical or medical terminology.

Lexical density: 53%

Factual content: The source and evidence base for the content was not given but the content consisted primarily of dosing instructions.

Format: Short paragraph read by a doctor to the patient.

Stone 1989

Source of information about intervention: Information provided by the authors in the published study.

Description of intervention: Video about anticoagulant therapy

Name of program: Not reported

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Produced by the study authors

Stated expertise of program developers: Not reported

Process of development and testing: The video was produced by the study authors but no information was provided about its development or testing

Relationship between developers and users: Health professional to patient

Availability: Not reported

Purpose: To teach patients starting anticoagulant medications about anticoagulant therapy

Content: The videotape reviewed the reasons for anticoagulant therapy, the complications of warfarin, how to monitor therapy and other general points about anticoagulant therapy

Target audience: Patients starting treatment with anticoagulants

Format: Videotape

Hardware required: Television and VCR

Media: Video and audio

Delivery: The video was viewed at the anticoagulation clinic

Length of program: 15 minutes

Number of times program was used: Once

Time point of delivery: Prior to starting anticoagulant medication

Success at reaching target audience: All participants viewed the video on site

Assistance: Not reported

Interactivity: No

Tailoring: No

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

Personal instruction

Lecture from one of two nurses specially trained in anticoagulation therapy. The nurse lecture was standardised and contained the same information as the videotape.

A question and answer session with a health professional was held following both the video and personal instruction.

Evaluation of intervention:

Generic structure: Based on the information provided by the authors the content was identical to that in the control intervention and included at least three moves: Summary of use; Account of side effects and Information regarding monitoring.

Rhetorical elements: Unable to assess

Tenor: Unable to assess

Metadiscourse: Unable to assess

Headings: Unable to assess

Technicality of language: Unable to assess

Lexical density: Unable to assess

Factual content: Unable to assess

Format: 15 minute videotape

Evaluation of comparators:

Generic structure: Based on the information provided by the authors the content was identical to that in the multimedia intervention and included at least three moves: Summary of use; Account of side effects and Information regarding monitoring.

Rhetorical elements: Unable to assess

Tenor: Nurse to patient

Metadiscourse: Unable to assess

Headings: Unable to assess

Technicality of language: Unable to assess

Lexical density: Unable to assess

Factual content: Unable to assess

Format: Standardised lecture given by one of two nurses

Trent 2010

Source of information about intervention: Copy of the video and information provided by the authors in the published study.

Description of intervention: Video about self‐care of PID in addition to standardised care.

Name of program: Pelvic inflammatory disease ‐ patient education video

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported but copyright at the end of the video was from 2005.

Stated expertise of content developers: Developed by the authors who are adolescent health specialists.

Stated expertise of program developers: The program was "created by a professional production team"

Process of development and testing: Video was developed by the authors "using the health belief model as a conceptual framework. It was refined through qualitative research with adolescents who had a history of STI".

Relationship between developer and user: Health professionals to patients.

Availability: Publicly available on "YouTube"

Purpose: To educate patients about PID self‐care in order to improve adherence

Content: "The video tells the story of PID as related by a universal patient created by the voices and images of seven different female adolescents. The video portrays the patient's interface with the health provider as well as the male partner's interface and allows the universal girl to acknowledge the barriers and benefits of PID self‐care while providing cues for action by the individual patient".

Target audience: Adolescent girls diagnosed with PID.

Format: Not reported

Hardware required: Not reported

Media: Video and audio with some simple diagrams and animations.

Delivery: The video was viewed at the clinical sites.

Length of program: Six minutes

Number of times program was used: Once

Time point of delivery: Patients viewed the video on the day they were diagnosed and prior to being discharged with a course of the medication.

Success at reaching target audience: All participants viewed the video on site.

Assistance: Not reported

Interactivity: No

Tailoring: No

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator: Standardised care consisting of detailed discharge instructions based on the 2006 Centre for Disease Control STD treatment guidelines, a 14‐day course of medication and a written hand‐out to facilitate self‐care.

Evaluation of intervention:

Generic structure: The content included five moves: Summary of use; Dosage instructions; Constraints on patient behaviour; Outline of benefits and Clinical contact available.

Rhetorical elements: The program predominantly informed patients but specific instructions were also provided in the final minute of the video.

Tenor: Patient to patient. However, actors were used rather than actual patients. A doctor was also shown but directed their conversation to the patient/actor.

Metadiscourse: The purpose of the program was not provided within the video. However, accompanying text stated that the video was intended to improve adherence to treatment, follow‐up care and partner notification. It is unclear whether this text was shown to patients who participated in the study.

Headings: None

Technicality of language: Medical terminology was used infrequently and when used, was accompanied by an explanation.

Lexical density: 36%. Calculated from the first minute of the video.

Factual content: Program producers, their institution and sources of funding were identified in the end credits. The year that the program was developed was identified from the copyright shown at the end of the program.

Format: Six minute video showing actors speaking directly to camera accompanied by a few simple diagrams and animations.

Evaluation of comparators:

Inadequate information was provided on which to base an assessment

Van Der Palen 1997

Source of information about intervention: Information provided by the authors in the published study.

Description of intervention: Video about the use of MDIs

Name of program: Not reported

Country of origin: Netherlands

Language: Dutch

Year program used in the study was produced: Not reported

Stated expertise of content developers: The videos were not designed for this study but were "readily available from various pharmaceutical companies"

Stated expertise of program developers: Not reported

Process of development and testing: Not reported

Relationship between developer and user: Not reported

Availability: The videos were available from the pharmaceutical companies at the time of the study

Purpose: To instruct patients on correct inhaler technique

Content: Not reported

Target audience: Patients using MDIs

Format: Videotape

Hardware required: Television and VCR

Media: Video and audio

Delivery: In the participant's home

Length of program: Not reported

Number of times program was used: Patients watched it a median of three times (range one to 50)

Time point of delivery: Patients had been using inhaled medications for at least one month

Success at reaching target audience: Patients were given the video to take home and it was reported that all of them watched it at least once during the study period.

Assistance: None

Interactivity: No

Tailoring: No

Source of information about comparators: Information provided by the authors in the published study.

Description of comparators:

1. Personal instruction

Patients demonstrated their inhaler technique to a pulmonary function technician. Errors in technique were then corrected using verbal instructions and visual demonstrations. Patients continued to demonstrate their technique until no errors were made.

2. Group instruction

A group of five to seven patients received instruction from a specialised registered nurse. Each patient demonstrated their inhaler technique in front of the group. The average session lasted 45 minutes.

3. Control group

The control group did not receive any education as part of this study.

Evaluation of intervention:

Inadequate information was provided on which to base an assessment

Evaluation of comparators:

Inadequate information was provided on which to base an assessment

Voris 1982

Source of information about intervention: Information provided by the authors in the published study which included the script for the educational program.

Description of intervention: Slide‐tape presentation about tricyclic antidepressants

Name of program: The Tricyclic Antidepressant Education Program

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Developed by the first author (psychiatric pharmacy fellow)

Stated expertise of program developers: Assistance from the Biomedical Communications Department at the University of Nebraska Medical Centre.

Process of development and testing: "The initial script and slide descriptions were written and sent to selected staff pharmacists and psychiatrists for review and to assure pharmaceutical and medical exactness." An education reading specialist tested the program for suitability for readers at the seventh grade level.

Relationship between developers and users: Health professionals to patients.

Availability: Not reported

Purpose: To increase both short‐term and long‐term knowledge about tricyclic antidepressants and depression.

Content: Program consisted of four sections: an introduction citing the objectives of the program; a section describing depression including possible causes, common signs and symptoms; the largest section dealing with facts on tricyclic antidepressants (basic mechanism of action, dosing, importance of maintaining adequate blood levels, common side effects and what to do if they occur, consequences of under and over‐dosing); and a brief conclusion.

Target audience: Adults who are commencing a tricyclic antidepressants

Format: Slide‐tape audiovisual presentation (either a carousel projector, screen and tape player or a carousel and a cassette playback synchronizer).

Hardware required: Carousel projector, screen and a cassette player.

Media: Text or still graphics and audio

Delivery: Viewed on a projector screen at the hospital.

Length of program: Seven minutes

Number of times program was used: Once

Time point of delivery: Patients had recently commenced a tricyclic antidepressant.

Success at reaching target audience: All participants viewed the presentation on site.

Assistance: The investigator was not present during the program but was available to answer questions at the completion of the presentation.

Interactivity: No

Tailoring: No

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

Usual care:

"Information which nurses and physicians decided to give them as part of the usual hospital routine."

Evaluation of intervention:

Generic structure: The education program contained seven moves: Background on drug, Summary of use, Dosage instructions, Side effects, Constraints on patient behaviour, Outline of benefits and Clinical contact available. Users were advised of situations in which they should contact their doctor but were not provided with information on how to do so.

Rhetorical elements: The education primarily informed and instructed patients. The function was unclear in some areas e.g. "The medicine works best when taken every day. Most people take their medicine at the same time every day" ‐ it is unclear whether this is informing patients of common practice or instructing them on when to take their medication.

Tenor: Health professional to patient. The identity of the authors and the intended user was clearly stated at the beginning of the program. The person responsible for actions is stated throughout.

Metadiscourse: There is a clear description of the purpose of the education in the introduction. This outlines what information the education will provide and what it is designed to teach patients.

Headings: Unable to assess

Technicality of language: The authors state that "the terminology used in the program was designed to be understood by the majority of patients' and that the program was suitable at the seventh grade reading level. Medical terminology was used but an explanation of its meaning was also provided.

Lexical density: 52%. Calculated from the script for the audiovisual presentation.

Factual content: The institutions involved in developing the content were identified. The script also alluded to some of the information being based on scientific studies.

Format: A seven minute slide‐tape audiovisual presentation

Evaluation of comparator:

Not applicable.

MDI ‐ Metered Dose Inhaler, PIL ‐ Patient Information Leaflet, PCA ‐ Patient Controlled Analgesia, INR ‐ International Normalised Ratio, OTC ‐ over‐the‐counter, EC ‐ Emergency Contraception, STD ‐ Sexually Transmitted Disease, STI ‐ Sexually Transmitted Infection, PID ‐ Pelvic Inflammatory Disease.

Generic structure

Sixteen multimedia programs, used in 18 studies, provided adequate information on which to base an assessment of their generic structure (Deitz 2011; Goodyer 2006; Kato 2008; Kinnane 2008; Mazor 2007; McElnay 1989; Navarre 2007; Neafsey 2001; Neafsey 2002; Olver 2009; Osguthorpe 1983; Powell 1995; Savage 2003; Schwarz 2008a; Solomon 1988; Stone 1989; Trent 2010; Voris 1982). The programs contained one to seven of the ten possible 'moves' or identifiable sections of medication information. The move 'Summary of use', which outlines what the medication does, was the most frequently used (in 11 programs). This was followed by 'Dosage instructions', 'Account of side effects' and 'Constraints on patient behaviour' which were each present in nine programs. None of the programs contained the 'Storage instructions' move. Three programs, used in four studies, which focused on instructing patients on the correct use of MDIs, included only one move ('Dosage instructions') (Goodyer 2006; McElnay 1989; Navarre 2007; Savage 2003).

Rhetorical elements

Eleven programs (used in 12 studies) provided adequate information on which to base an assessment of their rhetorical elements (Deitz 2011; Goodyer 2006; Kato 2008; Kinnane 2008; Mazor 2007; Navarre 2007; Olver 2009; Savage 2003; Schwarz 2008a; Solomon 1988; Trent 2010; Voris 1982). The two main rhetorical elements employed by the programs were 'to inform' and 'to instruct'. Most of the programs contained both elements. However, the program used in Goodyer 2006 and Solomon 1988 included only instructions regarding correct MDI use, while Mazor 2007 informed users about the management of oral anticoagulant medications without providing any direct instructions. In 10 of the 11 programs where the tenor was able to be assessed, the relationship with the user was health professional or medical expert to patient (Deitz 2011; Kato 2008; Kinnane 2008; Lirsac 1991; Navarre 2007; Olver 2009; Osguthorpe 1983; Schwarz 2008a; Solomon 1988; Voris 1982). Two of the programs also contained components where the relationship was patient to patient (Olver 2009; Solomon 1988) and one program consisted entirely of a patient to patient interaction (Trent 2010). In some of the programs, the relationship was explicit, e.g. the health professional introduced themselves or was clearly identified as a health professional based on their clothing and setting (Kato 2008; Mazor 2007; Navarre 2007; Olver 2009; Schwarz 2008a; Trent 2010; Voris 1982). However, in others the relationship was not explicitly stated but implied by the language used e.g. "during our care for you" (Deitz 2011; Kinnane 2008).

Metadiscourse

Ten programs used in 11 studies provided adequate information on which to base an assessment of their metadiscourse (the description of the purpose or structure of the program) (Deitz 2011; Goodyer 2006; Kato 2008; Kinnane 2008; Lirsac 1991; Navarre 2007; Olver 2009; Savage 2003; Schwarz 2008a; Trent 2010; Voris 1982). Of these, seven programs (used in eight studies) clearly stated their purpose, generally as part of their introduction (Deitz 2011; Goodyer 2006; Kato 2008; Kinnane 2008; Olver 2009; Savage 2003; Schwarz 2008a; Voris 1982). One program did not contain any metadiscourse but had separate text accompanying the video that explained the purpose of the program (Trent 2010). It was unclear whether this text was shown to patients who participated in the study.

Factual content

Eight programs provided adequate information on which to base assessment of their factual content (Deitz 2011; Kato 2008; Kinnane 2008; Mazor 2007; Navarre 2007; Olver 2009; Trent 2010; Voris 1982). The source of the information, i.e. the organisation who had developed the program, was identified in six of the programs (Kato 2008; Kinnane 2008; Navarre 2007; Olver 2009; Trent 2010; Voris 1982). This was mostly presented as an acknowledgement at the end of the program. None of the programs explicitly stated when the information was last updated. This information was implied from the copyright date presented in five programs (Kato 2008; Kinnane 2008; Mazor 2007; Navarre 2007; Trent 2010).

Lexical density

Lexical density was calculated as the percentage of content words within a program or a section from the program. The higher the lexical density, the more densely packed the information, which may make it more difficult to understand. Lexical density was able to be calculated for 9 of the programs used in 10 studies (Deitz 2011; Goodyer 2006; Kinnane 2008; Mazor 2007; Navarre 2007; Olver 2009; Savage 2003; Schwarz 2008a; Trent 2010; Voris 1982). Lexical density in the programs varied from 29% to 65%. The lowest lexical density was found in programs or sections of programs that depicted patients presenting information or having a conversation (Olver 2009 29%; Deitz 2011 31% and Trent 2010 36%).

Comparator

We were able to obtain a copy of the written information leaflet used as the comparator in four studies (Goodyer 2006; McElnay 1989; Savage 2003; Solomon 1988). Four other studies provided a description of the comparator on which to base a limited evaluation of its quality (Kinnane 2008; Osguthorpe 1983; Schwarz 2008a; Stone 1989). Information regarding the quality of the comparators is presented in Table 4. Insufficient information was available on which to evaluate the quality of the comparator or co‐interventions for the remaining eight studies (Acosta 2009; Lirsac 1991; Neafsey 2002; Olver 2009; Schnellinger 2010; Self 1983; Trent 2010; Van Der Palen 1997).

Comparators and co‐interventions

Multimedia versus usual care or no education

Ten studies compared multimedia education to usual care or no education (Deitz 2011; Knoerl 1999; Mazor 2007; Navarre 2007; Neafsey 2001; Osguthorpe 1983; Powell 1995; Schnellinger 2010; Van Der Palen 1997; Voris 1982). Usual care was defined as non‐standardised education that was provided by health professionals as part of standard clinical practice. Participants in the control groups did not received any education as part of the study. Of these ten studies, five recruited patients who were taking particular medications and then presented those randomised to the intervention group with multimedia education about that medication (Mazor 2007; Navarre 2007; Neafsey 2001; Powell 1995; Van Der Palen 1997). In three of these five studies, the inclusion criteria required that the patients had been taking the medication for a minimum period of time, ranging from one to six months. Two of the studies reported patients' mean duration of treatment, showing that it was five years or longer (Navarre 2007; Van Der Palen 1997). As education about medications is commonly provided at the time a medication is first prescribed, this suggests that many of the control group participants would not have received any recent education about their medications.

Three studies recruited patients who were recently started on a medication, and randomised them to receive multimedia education or usual care (Knoerl 1999; Osguthorpe 1983; Voris 1982). In Knoerl 1999 this consisted of informal and non‐standardised teaching about patient‐controlled analgesia (PCA) provided by hospital staff. In Osguthorpe 1983 and Voris 1982 psychiatric hospital inpatients and outpatients who were recently started on a medication received information provided by nurses and physicians as part of usual hospital care.

Two studies recruited participants from particular demographic groups which were the appropriate target for the educational intervention but were not necessarily receiving the medications of interest at that time, and compared the intervention to a control group which did not receive any education about the medication (Deitz 2011; Schnellinger 2010).

Multimedia versus other forms of education

Five studies compared multimedia education to written information (Goodyer 2006; Olver 2009; Savage 2003; Schnellinger 2010; Self 1983). Goodyer 2006, Savage 2003 and Self 1983 used patient information leaflets about MDIs, while Olver 2009 compared multimedia education to the hospital's standard information sheet and consent form for chemotherapy, and Schnellinger 2010 to an information pamphlet about antibiotic use and resistance. Both the multimedia education and written information groups from Olver 2009 were also provided with verbal information about their chemotherapy and the opportunity to ask questions of medical or nursing staff.

Six studies compared multimedia education to education provided verbally by a health professional (Goodyer 2006; Lirsac 1991; McElnay 1989; Self 1983; Stone 1989; Van Der Palen 1997). In McElnay 1989 and Self 1983, patients in the control arm were individually instructed in the use of MDIs by a pharmacist. McElnay 1989 also provided a custom designed printed instruction sheet outlining the steps required to use an MDI and the manufacturer's package insert for the MDI to both the control and multimedia arms. In Van Der Palen 1997, the comparators included personal instruction, in which patients received individual instruction in the use of MDIs by a pulmonary function technician, and group instruction, in which groups of five to seven patients were educated by a specialised registered nurse. In Stone 1989, individual patients received a standardised presentation, with content identical to the multimedia program, delivered by a nurse specially trained in anticoagulant therapy. In Goodyer 2006, the control arm was initially assessed after receiving written information. They then received personal instruction from a translator before being assessed again, providing results for the combination of written information and instruction from a health professional. In Lirsac 1991, patients received education from a doctor, who read from an instruction sheet outlining the correct use of MDIs, while patients viewed pictorial representations.

Three studies compared a multimedia education program to a control multimedia program (Acosta 2009; Kato 2008; Schwarz 2008a). In Schwarz 2008a the control program consisted of a multimedia program about another medication while Kato 2008 used a commercial computer game that contained no information about medications and Acosta 2009 used a video which contained general information about asthma. In Acosta 2009 and Kato 2008, the participants were all undergoing treatment with the medication of interest; therefore the control group would have received education or instruction about the medication from treating health professionals as part of usual care. In Schwarz 2008a, only 27% of participants in the control group had ever used emergency contraception. Therefore, it is likely that many in the control group had not received any education about this medication.

Multimedia and a co‐intervention versus the co‐intervention alone

Six studies compared multimedia education in combination with a co‐intervention to the co‐intervention alone, e.g. video plus written information versus written information alone (Kinnane 2008; McElnay 1989; Neafsey 2002; Osguthorpe 1983; Solomon 1988; Trent 2010). Two of these studies compared the multimedia intervention in combination with written patient education materials to the same written patient education materials alone (Neafsey 2002; Osguthorpe 1983). The written materials consisted of a drug information sheet about the medication (Osguthorpe 1983) and a patient information booklet (Neafsey 2002). One study compared multimedia and written education to written education alone, but used different written materials in the two arms (McElnay 1989). The multimedia education group received a custom designed instruction sheet outlining the steps required for correct MDI use in combination with the manufacturer's package insert for the MDI, while the written information group received only the manufacturer's package insert. Both the multimedia and control arms in Kinnane 2008 received a one‐hour standardised education session from a registered nurse, as well as written information about chemotherapy and the management of side effects. In Solomon 1988, patients from both the multimedia and control arms were provided with standardised verbal instructions from their doctor and randomised to receive special pill packaging labelled with instructions for when to take the medication, or no further intervention. The verbal instructions consisted of a single paragraph stating the name of the medication and instructions on how to take the medication correctly. In Trent 2010, all participants received standardised education including detailed discharge instructions, a 14‐day course of the medication and a written handout.

Outcome measures

Knowledge and skill acquisition

All but 2 of the 24 studies (Powell 1995; Trent 2010) measured either knowledge or skill acquisition and one study measured both (Navarre 2007).

Fifteen studies measured patient knowledge, each using different scales testing knowledge derived from the content of the educational interventions used in that study (Deitz 2011; Kato 2008; Kinnane 2008; Knoerl 1999; Mazor 2007; Navarre 2007; Neafsey 2001; Neafsey 2002; Olver 2009; Osguthorpe 1983; Schnellinger 2010; Schwarz 2008a; Solomon 1988; Stone 1989; Voris 1982). Fourteen of these studies used scales that were developed by the authors for the purpose of the study, while Schwarz 2008a used a pre‐existing questionnaire developed for a nationwide telephone survey about emergency contraception.

Skill acquisition was measured in eight studies that examined MDI technique in participants with asthma (Acosta 2009; Goodyer 2006, Lirsac 1991; Savage 2003; Self 1983), chronic obstructive pulmonary disease (COPD) (Van Der Palen 1997), asthma or COPD (Navarre 2007) and healthy volunteers (McElnay 1989). In all studies, MDI technique was assessed using inhaler checklists that outline the steps required for correct inhaler use. The inhaler checklists, as well as the methods used to observe and score inhaler technique, varied in each of the trials. However, the content of the different checklists was similar across the studies. Four of the seven studies reported that inhaler technique assessors were blinded (Acosta 2009; Goodyer 2006; McElnay 1989; Savage 2003).

Compliance or adherence

Five studies measured compliance or adherence to the prescribed medication (Kato 2008; Mazor 2007; Powell 1995; Solomon 1988; Trent 2010) while Mazor 2007 also measured patient compliance with laboratory monitoring. Trent 2010 measured compliance with medical instructions, including attendance at a 72‐hour follow‐up visit, abstinence from sexual activity while undergoing treatment for pelvic inflammatory disease, and the rates of notification and treatment of sexual partners. Solomon 1988 also measured rates of abstinence from sexual activity during the course of treatment.

The methods used to measure compliance varied. Mazor 2007 used a patient‐reported measure of non‐adherence that was developed by the authors for the purposes of this study. Powell 1995 monitored prescription refill data over a six month period. Kato 2008 assessed patient compliance with medications using five different measures: attendance at clinics; drug assays measuring levels of medication metabolites in blood tests; two existing measures of patient‐reported adherence (the Chronic Disease Compliance Instrument (CDCI) and the Medication Adherence Scale (MAS)); and the Medication Event Monitoring System (MEMS), which measures adherence to antibiotics using a medication container containing a microprocessor that records the dates and times the container is opened. Trent 2010 assessed medication adherence and adherence with other medical instructions using a telephone interview. Solomon 1988 also ascertained patient compliance using a telephone interview, but designed a scoring system where errors in medication compliance were given a numerical value according to the degree to which they might compromise treatment effectiveness.

Mazor 2007 measured compliance with the recommended laboratory testing required to monitor treatment with warfarin using two methods. Compliance was measured as the percent of patients who were documented to have missed at least one monitoring appointment, as well as the patient's reported intention to adhere to the laboratory testing using a two‐item scale, where higher scores represented a stronger intention to adhere.

Use of the study medication

Schwarz 2008a measured the number of patients who used emergency contraception or had a supply of emergency contraception in the home during the study period. Knoerl 1999 recorded PCA parameters, as well as the type and amount of analgesics used by patients in the post‐operative period. Deitz 2011 measured participants' self‐reported use of prescription medications for non‐medical purposes.

Health outcomes and medication side effects

Seven studies measured health outcomes. Knoerl 1999 measured patients' ratings of post‐operative pain on a scale of zero (no pain) to ten (worst possible pain). Lirsac 1991 measured bronchial obstruction using the forced expiratory volume (FEV) on spirometry and Acosta 2009 measured peak expiratory flow on a peak flow meter. Schwarz 2008a measured the number of patients who conceived during the study period, and Trent 2010 measured the rate of complications from pelvic inflammatory disease or its treatment.

Deitz 2011 used the CAGE questionnaire (Ewing 1984) to assess the risk of prescription drug misuse and addiction. Knoerl 1999 also recorded the incidence of medication‐related side effects. Although Neafsey 2002 did not directly measure the incidence of medication side effects, the authors developed a rating of patient self‐medication behaviours that were likely to lead to adverse events. This involved patients completing a questionnaire about their medication use behaviour, and the responses then being scored based on expert panel ratings of how likely each behaviour was to cause an adverse event, giving an overall adverse self‐medication behaviour score.

Other patient‐reported outcomes

Self‐efficacy was measured in four studies, each using different self‐efficacy questionnaires. All four of the studies used scales that were developed by the authors for the purpose of that study. Two of the studies measured self‐efficacy for avoiding drug and alcohol interactions with prescribed medications (Neafsey 2001; Neafsey 2002), Kato 2008 measured self‐efficacy to manage cancer and its treatment and Deitz 2011 measured self‐efficacy to take medications as prescribed and manage medication problems. Deitz 2011 also used an established scale (Perceived Efficacy in Patient‐Physician Interactions (PEPPI) Maly 1999) to measure patient self‐efficacy for obtaining medical information and attention for their medical concerns from physicians.

Five studies measured patients' satisfaction ‐ three measuring satisfaction with medical care (Deitz 2011; Knoerl 1999; Solomon 1988) and two measuring satisfaction with the education they received (Olver 2009; Stone 1989). Both Knoerl 1999 and Solomon 1988 measured patients' satisfaction with medical care using a single question with either a five‐ or six‐point Likert response scale. Olver 2009 and Stone 1989 measured patients' satisfaction with the education they had received using scales developed by the authors for the purpose of the study. Deitz 2011 used components of an established instrument (the Patient Feedback System (Forman 2003)) to measure patients' perceptions of their therapeutic alliance with caregivers, and satisfaction with treatment.

Five studies measured patients' attitudes or beliefs about medicines, each using different methods. Knoerl 1999 and Mazor 2007 used questionnaires that the authors adapted from existing measures. Knoerl 1999 modified the Ward's Barriers Questionnaire (Ward 1993) to measure patient attitudes to using narcotic pain medicine to relieve pain. Mazor 2007 modified the Beliefs about Medicines Questionnaire (Horne 1999) to measure patients' beliefs about warfarin and laboratory monitoring. Schnellinger 2010 used three questions relating to parents' attitudes to antibiotic prescribing using a yes/no response format. The remaining two studies used a single question measuring patients' attitudes to emergency contraception using a yes/no response format (Schwarz 2008a) or their confidence in the treatment using a five‐point rating scale (Solomon 1988).

Two studies measured patients' perceptions about their health. Solomon 1988 assessed patients' perception of the severity of their illness using a single question with a five‐point rating scale, while Kato 2008 measured patients' perception of their control over their health using an existing measure (the Multidimensional Health Locus of Control Scale). Deitz 2011 measured patients' perception of the care (directive guidance) they received from doctors and pharmacists using an established measure (the Purdue Pharmacist Directive Guidance Scale (Gupchup 1996)). Schnellinger 2010 measured patients' perception of the education they received using a single question asking if they had learnt something about antibiotics that they had not known previously.

Quality of life was measured in only one study (Kato 2008) using two existing questionnaires designed for adult (Functional Assessment of Cancer Therapy ‐ General (FACT‐G)) and paediatric (Paediatric Quality of Life Inventory (PQL)) populations.

Patient usage of the educational intervention

Only one study (Olver 2009) measured patient usage of the educational intervention, reporting patients' perception of how much of the information contained in the written or multimedia education they accessed and understood.

Use of health services

Two studies measured the use of health services. Stone 1989 reported the amount of time that was required for delivery of education via video or nurse lecture and for health professionals to answer patient questions after they had received the education. Kinnane 2008 measured the number and content of telephone calls from patients to the outpatient clinic during the study period. No studies measured economic outcomes.

Adverse effects of the educational intervention

Adverse effects of the educational intervention were measured in two studies using existing tools (Kato 2008; Olver 2009). Adverse effects were measured indirectly by determining patients' self‐perceived stress (Kato 2008) and self‐perceived anxiety (Olver 2009) before and after the educational interventions.

Excluded studies

Of the 122 studies that we examined in further detail, 10 were found to be duplicate publications of the same study and we excluded 87 from the review. The reasons for excluding these studies are listed in Characteristics of excluded studies. The most common reasons for exclusion were:

the primary focus of the educational intervention was not medications (N = 31),
the effect of the multimedia intervention on measured outcomes could not be separated from the effect of co‐interventions (N = 22), and
the intervention met the definition for a decision aid (N = 12).

We excluded a further nine studies because they did not contain any multimedia intervention. We excluded seven studies as there was inadequate information on which to determine their suitability for inclusion in the review. One of these studies was excluded after the authors were contacted and reported that the intervention consisted of text and still pictures, therefore not meeting the definition for multimedia (Jank 2009). We contacted the authors of two studies for further information but no response was received (Edworthy 1999; Peet 1996). Contact details for the other study authors were not available (Bakker 1999; Charles 1999; Petro 2005; Yakirevitch 2010). The published protocol of one study met criteria for inclusion in the review but the study is currently ongoing and results were not available at the time of this review (Smith 2010). We report details regarding this study in the Characteristics of ongoing studies table.

Risk of bias in included studies

Many of the studies provided inadequate information to allow a judgement to be made about the adequacy of their methods, resulting in an unclear risk of bias. Risk of bias is summarised below and in Figure 2, and further detail is provided in the Characteristics of included studies tables.

Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Allocation

Ten of the 24 studies reported adequate methods for sequence generation (Goodyer 2006; Kato 2008; Kinnane 2008; Lirsac 1991; Navarre 2007; Savage 2003; Schnellinger 2010; Schwarz 2008a; Trent 2010; Voris 1982). However, only four of these studies also reported adequate allocation concealment (Kato 2008; Kinnane 2008; Lirsac 1991; Trent 2010). The other six studies provided insufficient details on which to judge the adequacy of methods used. The methods used for both sequence generation and allocation concealment were inadequate in three studies (Knoerl 1999; Olver 2009; Stone 1989). The remaining 11 studies did not provide enough information to allow a judgement to be made about the adequacy of randomisation or allocation concealment methods.

Blinding

Blinding of participants is difficult in studies of educational interventions. Four studies reported the methods used to blind participants (Goodyer 2006; Kato 2008; Powell 1995; Schwarz 2008a). Participants in Goodyer 2006 and Kato 2008 did not have advance knowledge of the type of education that they would receive. This was considered adequate blinding in Goodyer 2006, where outcomes were measured immediately following the educational intervention, but not in Kato 2008, where outcomes were measured one and three months after the intervention. Powell 1995 and Schwarz 2008a attempted to blind participants by withholding information about the purpose of the study. In Powell 1995 the participants in the multimedia group were informed that the videotapes were part of a patient education program but they were not informed that their medication compliance was being assessed through prescription refill records. Participants in the control group received no education and presumably were not aware that they were participating in a study. Schwarz 2008a attempted to blind participants by not mentioning emergency contraception in the consent documents. Participants therefore did not know that there were intervention and control multimedia programs that were being compared. Two studies reported that the participants were not blinded (Savage 2003; Solomon 1988). In Savage 2003 outcomes were measured immediately following the intervention, minimising the potential for the lack of blinding influencing outcomes. The remaining 18 studies did not provide any information about participant blinding.

Eight studies reported that assessors were adequately blinded (Acosta 2009; Goodyer 2006; Kato 2008; McElnay 1989; Olver 2009; Savage 2003; Schwarz 2008a; Solomon 1988), while one study reported that they were not (Navarre 2007). The remaining 15 studies did not provide any information about blinding of assessors. Of these, four studies used subjective measures or patient interview where the lack of blinding of assessors could influence outcomes (Lirsac 1991; Self 1983; Trent 2010; Van Der Palen 1997). Powell 1995 used a completely objective outcome and the other 10 studies used patient‐reported questionnaires which minimised the potential for the lack of blinding of assessors influencing outcomes.

Incomplete outcome data

The missing outcome data were greater in the intervention (33%) than control groups (21%) in Mazor 2007. The reasons given for the missing data were also unbalanced. At least 13% of participants in the intervention group did not provide outcome data as they lacked access to a television or video recorder and could therefore not view the intervention. Lack of access to this technology did not preclude participation in the control arm. This imbalance is likely to impact on outcomes including knowledge through selection bias. Five studies did not report sufficient information about attrition or the reasons for missing data to allow a judgement about risk of bias (Deitz 2011; Osguthorpe 1983; Self 1983; Solomon 1988; Voris 1982). The remaining 18 studies adequately reported the reasons for missing outcome data, which were balanced across intervention groups, or reported no missing data.

Selective reporting

Five studies did not report results from all of the outcomes specified in their methods. Goodyer 2006 and Savage 2003 assessed inhaler technique using a checklist consisting of eight steps, but then only reported the results for a subset of 'key' steps that had not been pre‐specified. Both Olver 2009 and Osguthorpe 1983 did not report the results for two of the questions used in their knowledge or information recall instrument. The methods from Schwarz 2008a outlined that knowledge would be reported both limited to participants who completed follow‐up and using an intention‐to‐treat analysis, where it was assumed that participants lost to follow‐up had learnt nothing. However, only a P value was reported for the intention‐to‐treat analysis. The remaining 19 studies reported all outcomes that were specified in their methods. However, in Acosta 2009, although only inhaler technique scores were specified as outcomes in the study methods, peak flow was also measured at three time points. Results were only reported for measurements made at two of the time points.

Other potential sources of bias

The methods used by Mazor 2007 led to selection bias, as only participants who had access to a television or video recorder would have been able to watch the videotape and therefore participate in the study in the intervention arm, while lack of access to a television or video recorder did not exclude participants from the control arm. Non‐respondent numbers were higher in the intervention arm than in the control group. Lack of access to technology is more prevalent in groups with lower levels of educational attainment and from lower socioeconomic backgrounds. The exclusion of participants who did not have access to a television or video recorder from the intervention arm may therefore have led to selection of participants who were better educated and from a higher socioeconomic group in the intervention arm, potentially biasing the results for knowledge and skill acquisition in favour of the multimedia intervention.

There may have been a risk of recruitment bias in Osguthorpe 1983, a cluster randomised trial in which individuals were recruited to the study after the hospital wards had been randomised. The authors did not report whether staff involved in the recruitment and admission of patients were blinded to the ward allocation. Foreknowledge of the intervention assigned to each ward could have influenced the types of participants recruited. Osguthorpe 1983 did not account for cluster randomisation in statistical analyses and did not report outcomes in sufficient detail for them to be statistically adjusted for inclusion in the meta‐analysis.

Effects of interventions

The results of studies with sufficient data to be included in the meta‐analyses are displayed in the Data and analyses tables and are described below. A summary of the results from all of the studies, including those with insufficient data to be included in meta‐analyses, are displayed in Additional tables (Table 2) and are also described below. None of the included studies reported the minimum clinically important difference for the outcomes that were measured. We have therefore reported results from the studies, but have been unable to interpret whether differences were of clinical importance.

Multimedia education versus usual care or no education

Ten studies compared multimedia education to usual care or no education (Deitz 2011; Knoerl 1999; Mazor 2007; Navarre 2007; Neafsey 2001; Osguthorpe 1983; Voris 1982; Powell 1995; Schnellinger 2010; Van Der Palen 1997). We present the main findings for this comparator in summary of findings Table for the main comparison.

Knowledge

Eight of the 10 studies comparing multimedia education to usual care or no education measured knowledge. Six of these studies, with a total of 817 participants, provided sufficient data for meta‐analysis (Deitz 2011; Knoerl 1999, Neafsey 2001, Mazor 2007, Navarre 2007; Voris 1982). Voris 1982 reported mean scores with a score range but no standard deviation (SD) or other measure of variance from which the SD could be calculated. We therefore imputed the SD using the SD from the study with the greatest weight in the meta‐analysis (Mazor 2007). Pooled results from the six studies showed that participant knowledge, measured within four weeks of the intervention, was greater in the multimedia education group (SMD 1.04, 95% CI 0.49 to1.58, Analysis 1.1, Figure 3). A sensitivity analysis to examine the effect of the imputed SD shows that removal of Voris 1982 from the pooled analysis does not affect the results of the meta‐analysis (SMD 0.99, 95% CI 0.42 to 1.57).

Figure 3

Forest plot of comparison: 1 Multimedia education versus usual care or no education, outcome: 1.1 Knowledge (mean score, %).

Tests for heterogeneity revealed considerable heterogeneity (I² = 89%). Examination of the forest plot revealed that although there was heterogeneity with non‐overlapping confidence intervals, all but one of the studies (Deitz 2011) favoured the multimedia education group. Results of the meta‐analysis were unchanged when the fixed‐effect model was used.

Schnellinger 2010 reported that multimedia education performed better than the control group when knowledge was measured immediately after the intervention and four weeks later (P < 0.001) in 167 patients. However, data could not be extracted to verify this result as the authors reported the median and range of scores. From the scores, it was evident that results were skewed, with high knowledge scores at baseline. This suggested that the scale used was poorly targeted to knowledge levels in this population and therefore insensitive to change due to a ceiling effect. Schnellinger 2010 also reported that knowledge scores increased following the intervention in 71% of the multimedia education group compared with 28% of the control group (RR 2.26, 95% CI 1.39 to 3.67, Analysis 1.2). At baseline, 31% and 18% of participants had perfect scores in the multimedia education and control groups respectively; therefore improvement in knowledge following the intervention could not be detected in these participants. As the number with perfect scores was higher in the multimedia education group, this would be expected to underestimate the effect of the multimedia intervention.

The remaining study did not provide data in a format suitable for meta‐analysis. Osguthorpe 1983 reported no statistically‐significant difference one week after the educational intervention. The author attributed the lack of effect on the content of the intervention being overly simplified to the point that it did not add to baseline knowledge, and the outcome measure being insensitive to change.

Only Voris 1982 measured long‐term knowledge, although this was measured only four weeks after the intervention. Voris 1982 was a small study with only four patients remaining in each arm at this time point. While the authors reported that the results favoured the multimedia education group, when we analysed the results using the imputed SDs the results were not statistically significant (MD 22.50, 95% CI ‐0.42 to 45.40, Analysis 1.1).

Skill acquisition

Two of the studies comparing multimedia education to usual care or no education measured skill acquisition and provided sufficient data for meta‐analysis (Navarre 2007; Van Der Palen 1997). The studies examined MDI technique in a total of 94 participants and showed that inhaler technique was superior in the multimedia education group compared with usual care or no education (MD of inhaler technique score (percent) 18.32, 95% CI 11.92 to 24.73, Analysis 1.3). Van Der Palen 1997 reported an SD for the overall sample rather than separate SDs for the intervention and control groups. The individual group SDs for the meta‐analysis were imputed from the overall sample SD. The results of the meta‐analysis also favoured the multimedia education group if the Van Der Palen 1997 data were removed (MD 20.90, 95% CI 9.91 to 31.89).

Navarre 2007 measured inhaler technique directly after the educational intervention, while Van Der Palen 1997 measured it at the first scheduled clinic visit up to nine months later (mean of 19 weeks for the multimedia education group and 25 weeks for the usual care or no education group). The results from both studies were comparable, suggesting that the effect of multimedia education on inhaler technique may persist over time. There was no evidence of significant heterogeneity (I² = 0%).

Compliance

Compliance with medications

Two studies comparing multimedia education to usual care or no education measured patient compliance with prescribed medications (Mazor 2007; Powell 1995) in a total of 4552 patients. The methods used to measure compliance and the timing of assessments varied. Mazor 2007 used a patient‐reported measure of non‐adherence that was developed by the investigators for the purposes of this study and administered three weeks after the intervention. Powell 1995 monitored prescription refill data over a six month period. Both studies reported no significant difference in patient medication compliance between the intervention and control groups: 96% versus 97% compliance in Mazor 2007 and 46% versus 44% compliance in Powell 1995 (RR 1.02, 95% CI 0.96 to 1.08, Analysis 1.4).

Compliance with monitoring

Mazor 2007 also reported compliance with recommended laboratory testing to monitor treatment with warfarin in 232 patients. The study measured the percent of patients who were documented to have missed at least one monitoring appointment. This result was reversed to obtain the percent of patients who attended all monitoring appointments, and showed a trend favouring the multimedia education group (78% in the multimedia education group versus 66% in the control group, RR 1.17, 95% CI 0.96 to 1.43, Analysis 1.5). This study also reported the patients' intention to adhere to the laboratory testing using a two‐item scale where higher scores represented a stronger intention to adhere (score range one to five). The study reported no significant difference between the intervention and control groups (mean score for intervention 3.93 (SD 0.99) and control 3.81 (SD 0.96)).

Use of study medication

Knoerl 1999 recorded pain medication that was administered in the post‐operative period. The study found that there were no statistically‐significant differences between the multimedia education and control groups in the amount or type of narcotic administered by PCA, in other PCA parameters including loading dose, lockout interval and control button dose, the amount of narcotic administered by nurses, or the amount of supplemental analgesics used in conjunction with PCA. These findings could not be verified as the authors reported no data.

Deitz 2011 recorded patients' self‐reported use of prescription medications for non‐medical purposes, and found that there was no statistically‐significant difference between the multimedia education and usual care or no education groups. No data could be extracted for meta‐analysis as the results were reported separately for each group of medications with no overall incidence of non‐medical use reported.

Medication safety

Knoerl 1999 recorded the incidence of narcotic medication‐related side effects including nausea, vomiting, pruritis, respiratory depression, hypotension, sedation and urinary retention. There was no statistically‐significant difference in the incidence of each side effect between the intervention and control groups. These results were not included in the meta‐analysis as the authors did not report the overall incidence of side effects, instead providing the incidence of each individual side effect.

Health outcomes

Knoerl 1999 measured 72 patients' ratings of post‐operative pain on a scale of 0 (no pain) to 10 (worst possible pain) at 4, 8 and 24 hours after surgery, and found that there was no statistically‐significant difference between the intervention and control groups at all time points. At the 24 hour time point, patients reported mean pain scores of 3.00 (SD 2.10) and 3.50 (SD 2.10) in the intervention and control groups respectively (MD ‐0.50, 95% CI ‐1.44 to 0.44, Analysis 1.6).

Deitz 2011 measured the risk of prescription drug misuse and dependence in 329 participants using the CAGE screening tool. They reported lower scores (where lower scores indicate a lower risk of drug misuse or dependence) in the multimedia education group (mean score 0.49 (0.83) versus 0.86 (1.19), P = 0.038, MD ‐0.38, 95% CI ‐0.60 to ‐0.15, Analysis 1.7). Results from Deitz 2011 and Knoerl 1999 were not pooled as the health outcomes measured were considered clinically heterogenous.

Satisfaction with care

Two studies measured different aspects of patient satisfaction with care (Deitz 2011; Knoerl 1999). Results from the two studies were not pooled as the outcomes measured were considered clinically heterogeneous. Knoerl 1999 measured 72 patients' satisfaction with post‐operative pain management using a six‐point Likert scale, where one indicated patients were very satisfied and six indicated they were very dissatisfied. The study reported that, although patients in the multimedia education group were more satisfied at four hours (mean score 1.80 (SD 0.93) versus 1.40 (SD 0.68), P = 0.03) and eight hours (1.50 (SD 0.60) versus 1.20 (SD 0.37), P = 0.01) after their operation, the difference between the groups was no longer statistically significant the day after surgery (1.50 (SD 0.60) versus 1.20 (SD 0.41), P = 0.10). However, when we used the mean score to calculate the MD (reversing the scale so that a higher score represented greater satisfaction), the results at the day after surgery time point continued to favour the multimedia education group (MD 0.30, 95% CI 0.07 to 0.53, Analysis 1.8).

Deitz 2011 measured participants' satisfaction with treatment and their therapeutic alliance with their physician. The 345 participants were women working at two hospitals, 61% of whom were medical professionals or assistants. The participants were not required to have a medical condition or to have received any therapy. The authors reported no difference between the multimedia education and usual care or no education groups (mean score 30.20 (SD 5.81) versus 30.19 (SD 5.05), MD 0.01, 95% CI ‐1.14 to 1.16, Analysis 1.8).

Perception of care

Deitz 2011 measured patients' perception of the directive guidance (instructions on taking their medications properly) they received from doctors and pharmacists and found that there was no difference between the multimedia education and usual care or no education group (mean score 17.27 (4.40) versus 17.01 (4.07), MD 0.26, 95% CI ‐0.64 to 1.16, Analysis 1.9).

Self‐efficacy

Two studies measured self‐efficacy for different health‐related tasks (Deitz 2011; Neafsey 2001). The results from the studies were not pooled as the outcomes were judged to be clinically heterogeneous. Neafsey 2001 tested self‐efficacy for avoiding drug and alcohol interactions with prescribed medications in 60 patients. The study used a questionnaire developed by the authors that provided a mean self‐efficacy score of one to five, with higher scores indicating greater self‐efficacy. The authors reported that the multimedia education group had significantly greater self‐efficacy than the control group (multimedia education 3.14 (SD 0.90), control 1.76 (SD 0.99), MD 1.38, 95% CI 0.90 to 1.86, Analysis 1.10).

Deitz 2011 used separate measures to examine self‐efficacy in performing 3 different health‐related tasks in 343 participants. The measures tested self‐efficacy for taking medications as prescribed (medication adherence); managing medication problems; and obtaining medical information and attention for medical concerns from physicians (interacting with doctors). Data from the medication adherence self‐efficacy scale were extracted by consensus opinion of the review authors as its content was thought to be the most clinically relevant. The review authors were not aware of the results when making this decision. Deitz 2011 reported greater self‐efficacy for medication adherence in the multimedia education group, based on an analysis of covariance (ANCOVA) (mean score 58.82 (11.88) versus 56.88 (11.72), P = 0.013). However, when the mean scores were used to calculate the MD there was no statistically‐significant difference between the two groups (MD 1.94, 95% CI ‐0.56 to 4.44). Results reported by the study authors for the other measures of self‐efficacy were mixed. Multimedia education performed better than usual care or no education for "managing medication problems" self‐efficacy (P = 0.03) but the difference in mean scores between the two groups was very small (28.05 multimedia education versus 27.34 usual care or no education). There was no difference reported between the two groups for self‐efficacy in "interacting with doctors" (P = 0.69).

Beliefs about medication

Three studies comparing multimedia education to usual care or no education measured patients' beliefs about their medications using different questionnaires in each study (Knoerl 1999; Mazor 2007; Schnellinger 2010). The results from these three studies were not pooled due to the clinical heterogeneity in the types of beliefs measured and the methods used to measure them.

Knoerl 1999 assessed 72 patients' attitudes to using narcotic pain medicines to relieve pain using a six‐item questionnaire with agree, disagree and don't know response options. Each item was scored as correct or incorrect and the results reported as the mean percentage of correct responses. Higher scores indicated a more favourable attitude towards the medication. Knoerl 1999 reported that patients' mean belief scores were significantly higher in the multimedia education group (mean 96% (SD 9) versus 72% (SD 23), a result verified by our analysis (MD 23.20, 95% CI 15.24 to 31.16, Analysis 1.11).

Mazor 2007 evaluated 310 patients' beliefs about warfarin using a questionnaire with four sub‐scales with five‐point Likert response options (strongly agree to strongly disagree). Each of the scales had scores ranging from one to five, with higher scores representing more positive beliefs about warfarin. Three of the sub‐scales tested beliefs about warfarin while the other tested beliefs about laboratory monitoring. Results from the sub‐scale "warfarin is beneficial" were extracted by consensus opinion of the authors as its content was thought to be the most representative of the beliefs about warfarin scale. The review authors were not aware of the results when making this decision. The study authors reported a positive effect of the multimedia intervention on patients' belief that warfarin is beneficial compared with usual care or no education (P = 0.01) based on a regression analysis with the change score from baseline as the dependant variable. However, when we used the mean scores post‐intervention to calculate the MD, there was no statistically‐significant difference between the intervention and control groups (MD 0.13, 95% CI ‐0.06 to 0.32, Analysis 1.11). The reported baseline scores were similar in both groups. The results reported by the study authors for the other sub‐scales were mixed. Multimedia education performed better than usual care or no education for the "lab testing is important" sub‐scale (P = 0.01), but there was no significant difference for the "taking warfarin is worrisome" and "taking warfarin is confusing or difficult" sub‐scales.

Schnellinger 2010 evaluated 167 parents' attitudes towards antibiotics using three items with yes/no response options. Data from the item "Based on what you learned in the study, would you ever ask your paediatrician for an antibiotic if your child had one of the illnesses we talked about today?" were extracted by consensus opinion of the authors as the item's content was thought to be the most representative of parent attitude to antibiotics that the study aimed to change. The study authors reported a positive effect of multimedia education, with more parents in the multimedia education group stating that they would not inappropriately request antibiotics (71/83 versus 46/84, RR 1.56, 95% CI 1.26 to 1.93, Analysis 1.12). There was no significant difference between the multimedia education and control groups for the other two items "Do you think that doctors have an antibiotic for every infection?" and "If your child had one of the illnesses we talked about and you knew that the doctor would not give you an antibiotic, would you go see your doctor anyway?".

Perception of the education

Schnellinger 2010 evaluated 167 participants' perception of the education they received, asking if they "learnt something about antibiotics that they did not know before". Results favoured the multimedia education group (60/83 versus 25/84, RR 2.43, 95% CI 1.70 to 3.46, Analysis 1.13).

Outcomes not evaluated

None of the studies comparing multimedia education to usual care or no education evaluated the effect on quality of life.

Multimedia education versus other form of education

Nine studies compared multimedia education to another form of education. Five of the studies compared multimedia education to written education (Goodyer 2006; Olver 2009; Savage 2003; Schnellinger 2010; Self 1983), five compared it to education by a health professional (Lirsac 1991; McElnay 1989; Self 1983; Stone 1989; Van Der Palen 1997) and one study compared multimedia education to written education in combination with education from a health professional (Goodyer 2006). The main findings for these comparators are presented in summary of findings Table 2; summary of findings Table 3 and summary of findings Table 4 respectively.

Knowledge

Only three of the seven studies comparing multimedia to other forms of education measured knowledge. The results could not be pooled for meta‐analysis. Schnellinger 2010 compared multimedia education to a written intervention in 162 participants, and reported that multimedia education performed somewhat better at the four week time point (P < 0.04), but not immediately following the intervention. However, data could not be extracted to verify this result as the authors reported the median and range of knowledge scores. Knowledge was also reported as the number of participants whose score improved following the intervention. Improvement was seen in 58% of the multimedia education group and 71% of the written education group (RR 0.80, 95% CI 0.59 to 1.09, Analysis 2.1). However, 31% and 21% of participants had perfect scores at baseline in the video and pamphlet groups respectively, therefore improvement in knowledge following the intervention could not be detected in these participants. As the number with perfect scores at baseline was higher in the multimedia education group, this would be expected to underestimate the effect of the multimedia intervention.

Olver 2009 reported no significant difference in knowledge between the multimedia and written education groups in a study of 101 patients. Data could not be extracted to verify this result as the authors reported the number of correct responses for the individual knowledge questions without an overall summated knowledge score. Stone 1989 compared multimedia education to education by a health professional in a total of 22 patients. Patient knowledge was measured using true/false questions derived from the content of the educational intervention and developed by the authors for the purpose of the study. There was no significant difference in knowledge scores between the intervention and control groups (mean score intervention 87% (SD 8), control 89% (SD 8), MD ‐2.20 95% CI ‐8.83 to 4.43 Analysis 3.1).

Skill acquisition

Three studies comparing multimedia education to written education measured skill acquisition in a total of 184 participants and all provided sufficient data for meta‐analysis. Self 1983 reported inhaler technique using a continuous scale with results favouring multimedia education (mean score multimedia education group 85% (SD 25), control group 54% (SD 23), MD 31.00, 95% CI 10.15 to 51.85, Analysis 2.2). Goodyer 2006 and Savage 2003 reported the number of participants in whom inhaler technique improved following the intervention, with results favouring multimedia education (RR 2.14, 95% CI 1.33 to 3.44, Analysis 2.3, Figure 4). In Goodyer 2006 the control group participants, who had previously received written instruction about inhaler technique, then received personal instruction by a translator before their inhaler technique was re‐assessed. When global inhaler technique was evaluated following this additional instruction, there was no statistically‐significant difference in the number of participants in whom technique improved between the multimedia education and control groups (17/34 versus 15/35, RR 1.17, 95% CI 0.70 to 1.94, Analysis 4.1). Results of the meta‐analyses were unchanged when the fixed‐effect model was used.

Figure 4

Forest plot of comparison: 2 Multimedia education versus written education, outcome: 2.3 Skill acquisition (N who improved).

Four studies comparing multimedia education to education by a health professional measured skill acquisition in a total of 245 participants and provided sufficient data for meta‐analysis (Self 1983; Lirsac 1991; McElnay 1989; Van Der Palen 1997). The studies measured inhaler technique at different time points. McElnay 1989 and Self 1983 assessed inhaler technique immediately after the intervention and then repeated assessment at either 2 weeks (McElnay 1989) or between 1 to 16 weeks (mean 6 weeks) (Self 1983) after the intervention. Lirsac 1991 measured inhaler technique before and 15 days after the intervention and Van Der Palen 1997 assessed inhaler technique at the first scheduled clinic visit up to 9 months later (mean of 19 weeks for the multimedia education group and 23 weeks for those educated by a health professional). Meta‐analysis was performed separately for studies reporting short‐term skill acquisition (less than four weeks) (Lirsac 1991; McElnay 1989; Self 1983) and those reporting more long‐term skill acquisition (greater than or equal to four weeks) (Self 1983; Van Der Palen 1997).

Skill acquisition assessed within four weeks showed no difference between multimedia education and education by a health professional (MD inhaler technique score (percent) ‐1.01, 95% CI ‐15.75 to 13.72, Analysis 3.2). However, there was substantial statistical heterogeneity (I² = 68%). Examination of the forest plot revealed that Lirsac 1991 favoured the intervention while McElnay 1989 favoured the control and Self 1983 suggested no difference. Although the multimedia interventions used in the studies were similar, the control interventions differed. In McElnay 1989 and Self 1983, participants received personal instruction from a health professional consisting of a demonstration of correct inhaler technique. In Lirsac 1991 the health professional read out instructions for correct technique while the participant looked at illustrations. The participants were not shown a demonstration. This difference may account for the heterogeneity in the meta‐analysis. Removal of Lirsac 1991 showed a non‐significant trend favouring education by a health professional (MD ‐8.84, 95% CI ‐19.32 to 1.63). Skill acquisition measured after four weeks or more also showed a non‐significant trend favouring education by a health professional (MD ‐4.29, 95 %CI ‐17.23 to 8.65, Analysis 3.2, Figure 5). Results of the meta‐analyses were unchanged when the fixed‐effect model was used.

Figure 5

Forest plot of comparison: 3 Multimedia education versus education by a health professional, outcome: 3.2 Skill acquisition (mean score, %).

Van Der Palen 1997 reported an SD for the overall sample rather than separate SDs for the intervention and control groups. The individual group SDs for the meta‐analysis were imputed from the overall sample SD. Removal of the Van Der Palen 1997 data from the meta‐analysis for long‐term skill acquisition did not change the results, which continue to show a trend favouring education by a health professional (MD ‐15.50, 95% CI ‐36.92 to 5.92).

Health outcomes

Lirsac 1991 measured bronchial obstruction before and after using an MDI in 28 patients with poor MDI technique. The study authors reported that both groups had significant improvement in bronchial obstruction following MDI use at baseline despite poor technique. Fifteen days after receiving education, the multimedia education group had significant improvement in their FEV measured before using the MDI while the group who received education from a health professional did not (multimedia education group 1.89 to 2.38 litres (P < 0.001), control group 2.01 to 2.09 litres (not significant)). However, there was no difference in the mean FEV between the two groups (MD 0.29, 95% CI ‐0.26 to 0.84, Analysis 3.3). Both groups had improved FEV measurements following MDI use, but only the multimedia education group achieved FEV scores equivalent to their theoretical maximum.

Satisfaction

Satisfaction with education

Olver 2009 reported patients' satisfaction with the education they had received, stating that 66% found the information very or somewhat helpful, and that 54% felt that they had received the right amount of information. The study authors reported that there were no significant differences between the written education and multimedia education groups on these variables. No data could be extracted to verify these results. Stone 1989 measured patient satisfaction with the education they received using a 12‐item satisfaction questionnaire with a maximum satisfaction score of 25. The authors reported no significant differences between multimedia education and education by a health professional, with mean satisfaction scores of 23.20 and 24.80 respectively. Data could not be extracted for meta‐analysis from this study as the SD was not reported and could not be calculated or imputed from other studies.

Use of health services

Stone 1989 reported the amount of time that was required for delivery of the education via video or nurse lecture and for health professionals to answer patient questions following the education. The duration of the video was 17.6 minutes while the nurse lecture presentation had a mean duration of 26 minutes (SD 5.7). The authors reported that there was no statistically‐significant difference in the time required for questions between the groups (mean time in minutes: multimedia education 7.5 (SD 7.2), nurse lecture 6.3 (SD 5.3)).

Beliefs about medication

Schnellinger 2010 evaluated parents' attitudes towards antibiotics. The study authors reported a positive effect of multimedia education compared with written information, with more parents in the multimedia education group stating that they would not inappropriately request antibiotics from health professionals (71/83 versus 51/79, RR 1.33, 95% CI 1.10 to 1.60, Analysis 2.4). There was no significant difference between the multimedia and written education groups for the other two items.

Patient usage of the education

Olver 2009 recorded patients' perception of how much of the information contained in the written or multimedia education they accessed and understood. They reported that overall, 28% of patients understood all of the information presented and that there was no significant difference in understanding between the multimedia and written education groups. The information provided was read in its entirety by 46% of patients with no significant difference between the groups. No data could be extracted in order to verify these findings.

Perception of the education

Schnellinger 2010 evaluated participants' perception of the education, asking if they "learnt something about antibiotics that they did not know before". There was no significant difference between the multimedia (60/83) and the written education (66/79) groups (RR 0.87, 95% CI 0.73 to 1.02, Analysis 2.5).

Adverse effects of the educational intervention

Olver 2009 measured patients' perception of their anxiety level after the educational intervention. The authors reported combined scores from both groups, with 11% feeling more anxious, 30% feeling less anxious and 33% feeling the same level of anxiety after receiving written or multimedia education. The authors stated that there was no significant difference between the groups but no data could be extracted to verify this.

Outcomes not evaluated

None of the studies comparing multimedia education to written education evaluated the effect on compliance with medications, health outcomes, medication side effects, quality of life or self‐efficacy. None of the studies comparing multimedia education to education by a health professional evaluated the effect on compliance with medications, medication side effects, quality of life or self‐efficacy. The single study that compared multimedia education to the combination of written education and education by a health professional only examined the effect on skill acquisition.

Multimedia education versus control multimedia

Three studies compared multimedia education to a control multimedia program (Acosta 2009; Kato 2008; Schwarz 2008a). We present the main findings for this comparator in summary of findings Table 5.

Knowledge

Two studies comparing multimedia education to a control multimedia program measured knowledge in a total of 568 patients. Kato 2008 measured knowledge before the intervention, and one and three months after the intervention. Baseline knowledge levels were comparable, but the study authors reported a significantly greater increase in knowledge over time in the intervention group (P = 0.035). Although there was a slightly greater change in mean scores from baseline to the three month time point in the intervention group (59% to 66%) than the control group (60% to 63%) there was no statistically‐significant difference in the mean scores at the three month time point (66% versus 63%, MD 3.00, 95% CI ‐1.52 to 7.52, Analysis 5.1, Figure 6). Schwarz 2008a measured knowledge about emergency contraception at baseline and six months later, and reported that significantly more patients in the multimedia education group than the control group learned one or more things about emergency contraception (76% and 62% respectively). Mean scores for the knowledge test were not reported in the study but were made available by the authors on request. Baseline scores in both groups were comparable (59% intervention and 62% control group, P = 0.12) and there was no difference in mean scores between the two groups at six months (mean score 59% intervention versus 58% control group, P = 0.88). Pooled data from both studies revealed no difference in mean scores between the two groups (MD 2.78, 95% CI ‐1.48 to 7.05).

Figure 6

Forest plot of comparison: 5 Multimedia education versus control multimedia, outcome: 5.1 Knowledge (mean score, %).

Skill acquisition

Acosta 2009 measured inhaler technique in 116 patients immediately before and after the intervention and at one month follow‐up. The change from baseline score (percent of steps performed correctly) in the post‐intervention time point was significantly higher in the multimedia education group: 15.92 (SD 15.04) compared with the control group: 1.16 (SD 6.55) (MD 14.76, 95% CI 10.63 to 18.89, Analysis 5.2). This difference was maintained after one month with a change of score from baseline of 14.92 (SD 15.49) in the multimedia education group and 1.62 (SD 7.30) in the control group (MD 13.30, 95% CI 8.98 to 17.62, Analysis 5.2).

Compliance with medications

Kato 2008 assessed patient compliance with medications in 303 patients using 5 different measures: attendance at clinics, 6‐MP blood metabolite assays (indicate adherence to 6‐MP), Chronic Disease Compliance Instrument or CDCI (a patient‐reported measure of adherence to medical treatment), Medication Adherence Scale or MAS (a patient‐reported measure of general adherence to treatment) and the Medication Event Monitoring System or MEMS (which measures adherence to antibiotics using a medication container containing a microprocessor that records the dates and times the container is opened). Data from the CDCI were chosen for the meta‐analysis as the CDCI was measured in all study participants and it had better measurement properties than the MAS. CDCI scores ranged from 18 to 90 with higher scores representing better compliance. Outcomes were measured before the intervention, then one and three months following the intervention. The three‐month time point was used for the analysis.

For the CDCI results, the authors stated that there was no statistically‐significant difference in compliance between the intervention and control groups when analysed using a repeated‐measures mixed‐effect linear model that tested differences between treatment groups at the three time points (P = 0.78). However, when we used the unadjusted means from the three month time point, the results favoured multimedia education (MD 2.60, 95% CI 0.78 to 4.42, Analysis 5.3). The unadjusted means show that the level of compliance was higher in the intervention than the control groups at baseline (79.20 (SD 7.90) versus 77.40 (SD 7.50)). It is therefore possible that our result could be confounded by the higher levels of baseline compliance in the intervention group.

Results for the other compliance measures were mixed. There was no significant difference between compliance in the intervention and control groups when measured using the patient‐reported MAS (P = 0.50). However, objective measures of compliance demonstrated higher medication compliance in the multimedia education group (MEMS P = 0.01, 6‐MP assay P = 0.04). The objective measures were only available for the subset of patients who were prescribed that particular medication (MEMS in 200/304 and 6‐MP assay in 46/304 patients). Compliance with clinic attendance (percentage of scheduled visits that patients attended) was equally high in both the intervention and control groups (mean 98% +/‐ 1% in both groups, P = 0.65).

Use of study medication

Schwarz 2008a measured the number of patients who used emergency contraception during the seven‐month study period. The study found that there was no statistically‐significant difference in the percentage of enrolled patients who accessed emergency contraception in the intervention and control groups (6% versus 3%, RR 2.25, 95% CI 0.87 to 5.80, Analysis 5.4). However, patients in the multimedia education group were more likely to have a supply of emergency contraception at home (34% vs 7%, P < 0.001).

Health outcomes

Schwarz 2008a measured the number of patients who conceived during the study period and found that there was no statistically‐significant difference between the intervention and control groups (3% vs 6%, P = 0.12). The study authors did not report whether these were planned pregnancies or resulted from lack of patient knowledge on the use of emergency contraception. Acosta 2009 reported that peak flow readings following the intervention (controlled for pre‐intervention peak flows) were statistically better in the intervention group (P = 0.001). This was confirmed when the MD was calculated using SDs obtained from the reported 95% CIs (MD of peak flow readings (litres per second) 21.24, 95% CI 5.28 to 37.20, Analysis 5.5).

Self‐efficacy

Kato 2008 measured perceived self‐efficacy to manage cancer and its treatment in 303 patients. Self‐efficacy was measured using a scale designed for the purpose of this study, with possible scores ranging from 7 to 189 where higher scores reflect greater self‐efficacy. The study analysed results using a mixed‐effect linear model and found that patients in the intervention and control groups had similar levels of self‐efficacy at baseline. There was a significant increase in self‐efficacy over time in the intervention group (P = 0.01). Calculation of the MD using the mean self‐efficacy scores post‐intervention also favoured the multimedia education group (intervention 164.00 (SD 23.40), control 158.80 (SD 23.50), MD 5.30, 95% CI 0.00 to 10.60, Analysis 5.6).

Quality of life

Kato 2008 measured quality of life (QOL) using two established questionnaires designed for adult (Functional Assessment of Cancer Therapy ‐ General (FACT‐G)) and paediatric (Paediatric Quality of Life Inventory (PQL)) populations. QOL was measured one and three months following the intervention. The authors stated that there was no significant difference in QOL between the intervention and control groups over the different time points (PQL P = 0.11, FACT‐G P = 0.15). The results from the paediatric and adult sub‐groups, at the three month time point, were pooled (N = 269), showing a trend favouring multimedia education, although this did not reach statistical significance (SMR 0.20, 95% CI ‐0.04 to 0.44, Analysis 5.7).

Beliefs about medication

Schwarz 2008a measured patient attitudes towards emergency contraception in 446 participants and found that there was a trend favouring the intervention, with a greater number of participants developing a more positive attitude towards emergency contraception after the multimedia intervention (8% versus 4%, RR 1.73, 95% CI 0.64 to 4.67, Analysis 5.8).

Health locus of control

Kato 2008 measured 303 patients' perception of their control over their health using the Multidimensional Health Locus of Control Scale, and found that there was no significant difference between the intervention and control groups (P = 0.61). We were unable to extract data to verify this result, as the authors reported mean scores for each of the questionnaire's individual dimensions but not an overall locus of control score.

Adverse effects of the educational intervention

Kato 2008 measured 301 patients' self‐perceived stress using the Perceived Stress Scale. Possible scores for this scale range from 10 to 50, with higher scores representing greater stress. The study reported that there was no significant difference between the intervention and control groups using a repeated‐measures mixed‐effect linear model that tested differences between treatment groups at the three time points. When the unadjusted mean scores from the three month time point were used to calculate the MD, the results suggested that self‐perceived stress levels were higher in the intervention group (intervention 38.10 (SD 6.90), control 35.70 (6.20), MD 2.40, 95% CI 0.92 to 3.88, Analysis 5.9). Baseline levels of self‐perceived stress were higher in the intervention than control group (34.40 (SD 7.40) versus 33.10 (SD 6.60)). It is therefore possible that our result could be confounded by the higher levels of baseline self‐perceived stress in the intervention group.

Outcomes not evaluated

None of the studies comparing multimedia education to a control multimedia program evaluated the effect on medication side effects.

Multimedia education and a co‐intervention versus the co‐intervention alone

Six studies compared multimedia education in combination with a co‐intervention to the co‐intervention alone (Kinnane 2008; McElnay 1989; Neafsey 2002; Osguthorpe 1983; Solomon 1988; Trent 2010). We present the main findings for this comparator in summary of findings Table 6.

Knowledge

Four studies comparing multimedia education with a co‐intervention to the co‐intervention alone measured knowledge (Kinnane 2008; Neafsey 2002; Osguthorpe 1983; Solomon 1988). Two of the studies, with a total of 381 patients, provided sufficient data for meta‐analysis. Neafsey 2002 measured knowledge immediately after patients had received education, as well as two and four weeks later. The authors reported that knowledge scores were significantly higher in the multimedia education group at all of the time points. Calculation of the MD using mean scores from the two week time point (intervention 78% (SD 21) versus control 55% (SD 20), MD 22.40, 95% CI 12.15 to 32.65) and four week time point (intervention 80% (SD 21), control 57% (SD 20), MD 23.20, 95% CI 12.82 to 33.58) confirmed higher knowledge levels in the multimedia education group. Solomon 1988 evaluated patient knowledge on either the second or sixth day after the intervention, with the results strongly favouring the multimedia education group (mean score intervention 96% (SD 11), control 71% (SD 11). Pooled results for short term (less than four weeks) knowledge from both Solomon and Neafsey strongly favoured the multimedia education group (MD 24.59, 95% CI 22.34 to 26.83, Analysis 6.1, Figure 7). Results of the meta‐analysis were unchanged when we used the fixed‐effect model.

Figure 7

Forest plot of comparison: 6 Mulitmedia education and a co‐intervention versus co‐intervention alone, outcome: 6.1 Knowledge (mean score, %).

Kinnane 2008 and Osguthorpe 1983 measured patient knowledge but did not provide sufficient data for meta‐analysis. Both studies reported results for each of the knowledge questions individually, with no overall summated knowledge score. The authors of both studies reported no statistically‐significant difference in knowledge between the intervention and control groups.

Skill acquisition

McElnay 1989 compared inhaler technique in healthy volunteers receiving written information in combination with a multimedia education program to those receiving written information alone. Inhaler technique was measured in 87 volunteers immediately following the education and two weeks later. Results from the first time point indicated greater inhaler technique scores in the multimedia education group, with mean scores of 75% versus 62% (MD 13.10, 95% CI 6.16 to 20.04). However, testing of inhaler technique two weeks later showed that this difference between the two groups was not maintained, with scores of 63% versus 59% (MD 3.40, 95% CI ‐8.30 to 15.10, Analysis 6.2). The authors postulated that the deterioration in inhaler technique scores over the two weeks may have been due to the healthy volunteers not using the inhalers between the two time points, and hypothesised that scores at the second time point would be higher in an asthmatic population who were using inhalers daily.

Compliance

Compliance with medications

Two studies measured compliance with medications. We did not pool the results, as data from both studies could not be converted to dichotomous or continuous measures. Solomon 1988 measured patient compliance in 321 patients. Compliance was assessed via interviews with patients and scored using a system, devised by the authors for the purposes of this study, that assigned a numerical value according to the degree to which that error might compromise treatment effectiveness. Possible scores ranged from 0 to 160, with higher scores indicating worse compliance. The study reported that patients in the multimedia education group had significantly better compliance scores than those who did not view the multimedia intervention, and this result was confirmed when the MD was calculated from the mean scores (multimedia education 8.3 (SD 86.6) versus control 40.45 (SD 86.6), MD ‐32.15, 95% CI ‐51.13 to ‐13.17, Analysis 6.3).

Trent 2010 measured compliance with medications in 77 patients. Compliance was assessed via telephone interviews where participants were asked if they had completed a two week course of antibiotics. There was no difference in compliance rates between the two groups (intervention 23/36, control 27/41, RR 0.97, 95% CI 0.70 to 1.35, Analysis 6.4).

Compliance with treatment instructions

Solomon 1988 examined the percentage of patients who prematurely resumed sexual activity while being treated with tetracycline for a sexually transmitted disease. The authors reported that a smaller percentage of patients prematurely resumed sexual activity in the multimedia education group (median percentage 3% versus 22%, F‐ratio = 30.2, P < 0.001). These results could not be verified as the authors only reported the median number of patients.

Trent 2010 measured patient compliance with treatment instructions, including the number of participants who attended a medical follow‐up appointment, abstained from sexual intercourse during treatment, and notified their partners of the sexually transmitted disease diagnosis and the number of partners who were then treated. We extracted patient attendance at the follow‐up appointment, as this was identified as a primary outcome measure by the study authors. The authors reported that there was a higher rate of compliance with the follow‐up appointment in the multimedia education group (11/36 (31%) versus 6/41 (15%), RR 2.09, 95% CI 0.86 to 5.08, Analysis 6.5). The multimedia education group also had higher rates of partner treatment (67% versus 49%) but there was no significant difference in rates of sexual abstinence (69% versus 76%) or partner notification (83% versus 85%).

Health outcomes

Trent 2010 measured complications from pelvic inflammatory disease or its treatment, and found that there was no difference between the multimedia education and control groups (13/36 (36%) versus 13/41 (32%), RR 1.14, 95% CI 0.61 to 2.13, Analysis 6.6)

Adverse medication behaviour

Neafsey 2002 measured adverse self‐medication behaviour (patient medication behaviours that were likely to lead to adverse events) in a total of 60 patients. Possible scores ranged from 0 to 40, with higher scores representing greater risk for adverse events. The authors reported a significant decrease in the adverse behaviour score compared with baseline measurements for patients receiving multimedia and written education, but not those receiving written information alone. There were no significant differences in group scores at baseline. The statistical significance of the difference in behaviour scores between the multimedia education and control group following the intervention was not reported. When the MD was calculated from the mean scores, it revealed a trend favouring the multimedia education arm which became more evident with time from the intervention (at two weeks MD ‐4.00, 95% CI ‐9.98 to 1.98; at four weeks MD ‐5.00, 95% CI ‐10.06 to 0.06, Analysis 6.7).

Self‐efficacy

Neafsey 2002 measured self‐efficacy for avoiding drug and alcohol interactions with prescribed medications in a total of 60 patients, using a self‐efficacy questionnaire that was developed by the authors for the purpose of this study. Possible scores ranged from zero to five, with higher scores representing greater self‐efficacy. The authors reported higher self‐efficacy in the multimedia and written education group compared with the group that received the written information alone. This effect persisted from immediately following the intervention (mean score intervention 3.70 (SD 0.80), control 2.80 (SD 0.90), MD 0.90, 95% CI 0.47 to 1.33, Analysis 6.8), to the last time point at which outcomes were measured, four weeks after the intervention (intervention 3.90 (SD 0.70), control 3.00 (SD 0.80), MD 0.90, 95%CI 0.52 to 1.28 Analysis 6.8).

Satisfaction with care

Solomon 1988 assessed patients' satisfaction with care using a five‐point rating scale. We could not extract data for this outcome as the effect of the multimedia intervention could not be separated from that of the special pill packaging. However, the authors reported that patients who had received the multimedia intervention, the pill packaging or both had significantly higher satisfaction than those who had received neither intervention.

Beliefs about medication

Solomon 1988 assessed patients' confidence in the treatment regimen using a five‐point rating scale. We could not extract data for this outcome as the effect of the multimedia intervention could not be separated from that of the special pill packaging. However, the authors reported that patients who had received the multimedia intervention, the pill packaging or both had significantly greater confidence than those who had received neither intervention.

Perception of illness

Solomon 1988 assessed patients' perception of the severity of their illness using a five‐point rating scale. We could not extract data for this outcome as the effect of the multimedia intervention could not be separated from that of the co‐intervention. However, the authors reported that patients who had received the multimedia intervention, the pill packaging or both had significantly higher ratings of perceived disease severity than those who had received neither intervention.

Use of health services

Kinnane 2008 measured the number and content of telephone calls from patients to the outpatient clinic during the study period. The education provided to patients included information about the circumstances in which patients were to contact the clinic. The study reported no significant difference in the number of calls made by the multimedia and control groups (25 and 27 telephone calls respectively). However, the study authors noted that calls made by the multimedia education group were more likely to be about medical problems covered in the education (80% and 56% of the telephone calls respectively).

Outcomes not evaluated

None of the studies comparing multimedia education in combination with a co‐intervention to the co‐intervention alone evaluated the effect on quality of life.

Sensitivity analysis

We performed sensitivity analyses examining the effect of adequate allocation concealment and blinding of outcome assessors on the effect size of knowledge and skill acquisition. There were three studies appropriate for sensitivity analysis of the effect of allocation concealment on the effect size of skill acquisition in the multimedia education versus education by a health professional comparison group (Lirsac 1991; McElnay 1989; Self 1983). Results of the analysis with the inclusion of the three studies showed no difference between the multimedia education and comparison groups (MD ‐1.01, 95% CI ‐15.75 to13.72). The results continued to show no statistically‐significant difference when only data from the study at low risk of bias were examined (Lirsac 1991) (MD 10.00, 95% CI ‐3.48 to 23.48).

There were two studies appropriate for sensitivity analysis of the effect of blinding of outcome assessors on the effect size of knowledge in the multimedia education and co‐intervention versus co‐intervention alone comparison group (Neafsey 2002; Solomon 1988). Results of the analysis did not change with the inclusion of both studies (MD 24.59, 95% CI 22.34 to 26.83) or only data from the study at low risk of bias for the blinding of assessors (Solomon 1988) (MD 24.70, 95% CI 22.40 to 27.00). Three studies measuring skill acquisition in the multimedia education versus education by health professionals comparison group were also appropriate for sensitivity analysis of the effect of blinding of assessors (Lirsac 1991; McElnay 1989; Self 1983). The results when the three studies were included showed no difference between the multimedia education and control group (MD ‐1.01, 95% CI ‐15.75 to 13.72). When data from the study at low risk of bias for the blinding of assessors were included (McElnay 1989), the results showed a trend favouring education by a health professional (MD ‐11.90, 95% CI ‐22.86 to ‐0.94). As was discussed earlier, the variability of results from these studies may reflect differences in the education received in the control groups.

Discussion

Summary of main results

This systematic review summarises the evidence from randomised controlled trials of multimedia educational interventions about prescribed and over‐the‐counter medications. We identified 24 studies that enrolled a total of 8112 participants. However, due to variability in the comparators and outcomes measured, results from the review were based on subsets of these studies and participants. Although the studies varied in the outcomes that they measured, all but two measured our primary outcomes of interest ‐ knowledge and/or skill acquisition. The heterogeneity in the outcomes reported and the instruments used to measure these outcomes limited meta‐analysis for all comparisons. We were unable to comment on the clinical importance of results due to lack of information regarding the minimum clinically important difference of the outcomes measured. Also, variability of the aims and content of the multimedia and control educational interventions, and lack of information on which to base evaluation of their quality, limited conclusions from this review.

Summary of results

Knowledge

This review provides evidence that multimedia education is superior to no education or non‐standardised education provided as part of usual clinical care in improving patient knowledge (SMD 1.04, 95% CI 0.49 to1.58, six studies with 817 participants: RR 2.26, 95% CI 1.39 to 3.67, one study with 817 participants). There was considerable statistical heterogeneity (I² = 89%), however, all but one of the studies favoured the multimedia group. The review found that multimedia education was not superior to control multimedia interventions (i.e. multimedia programs that do not provide information about the medication) in improving knowledge (two studies with 568 participants: MD 2.78, 95% CI ‐1.48 to 7.05). The amount of information provided to the control group participants about the relevant medications varied and, in some instances, appeared to inversely correlate with the size of the effect of the multimedia intervention.

The review provides evidence that multimedia education has a superior effect on knowledge when added to co‐interventions consisting of written information or brief standardised information provided by a health professional compared with the co‐interventions alone (two studies with 381 participants: MD 24.59, 95% CI 22.34 to 26.83). Multimedia education was only compared to written education in a single study with methodological limitations that would be expected to underestimate the effect of the multimedia education. In this study, multimedia education was equally effective as written information (one study with 162 participants: RR 0.80, 95% CI 0.59 to 1.09). A single study also showed that multimedia education was equally effective as a standardised 25‐minute lecture provided by a health professional which had identical content to the multimedia intervention (one study with 22 participants: MD 2.2, 95% CI ‐8.83 to 4.43). The inconsistency of results in comparing multimedia education to that provided by a health professional may be explained by differing content and quality of the education provided in the control group. Overall, the results suggest that multimedia education is superior to brief standardised education provided by a health professional but not to more intensive interventions where the health professional provides the same or similar information to what is included in the multimedia education program.

Skill acquisition

All of the studies measuring skill acquisition were evaluating education about metered dose inhalers. The review found that multimedia education was more effective at improving skill acquisition than usual care or no education (MD 18.32, 95% CI 11.92 to 24.73, two studies with 94 participants), written education (MD 31.00, 95% CI 10.14 to 51.85 and RR 2.14, 95% CI 1.33 to 3.44, three studies with 184 participants) and a control multimedia intervention (MD 13.30, 95% CI 8.98 to 17.62, one study with 116 participants). Multimedia education was equally effective as education by a health professional (three studies with 130 participants: MD ‐1.01, 95% CI ‐15.75 to 13.72). However, there was substantial statistical heterogeneity (I² = 68%) in this meta‐analysis which may have been due to differences in the content and quality of the education used as a comparator.

Multimedia education was equally effective as the combination of written education and education by a health professional (one study with 69 participants: RR 1.17, 95% CI 0.7 to 1.94). Multimedia education was also equally effective when added to a co‐intervention consisting of written education compared with written education alone (one study with 87 participants: MD 3.40, 95% CI ‐8.30 to 15.10). This is inconsistent with the results from other studies that used written education as a comparator. The results from this study did show that multimedia education was more effective when the outcome was measured immediately following the intervention. but the effect was not maintained at two weeks which is the time point extracted for meta‐analysis. The study used healthy volunteers, and the study authors postulated that the deterioration in inhaler technique scores over the two weeks may have been because the volunteers, unlike asthma patients, were not using the inhalers between the two time points.

Compliance

The review found that multimedia education did not improve compliance with medications compared with usual care or no education (RR 1.02, 95% CI 0.96 to 1.08, two studies with 4552 participants).

Other outcomes

We were not able to pool data for any other outcome measures. Only two studies measured potential adverse effects from the educational intervention and both did so indirectly by determining patients' self‐perceived stress or anxiety before and after the intervention (Kato 2008; Olver 2009). Data could only be extracted from one study, comparing multimedia education to a control multimedia program. These data suggest that self‐perceived stress levels were higher in the multimedia education group (MD 2.40, 95% CI 0.92‐ 3.88). However, baseline levels of self‐perceived stress were higher in the intervention group, which may have confounded the result.

Overall completeness and applicability of evidence

Multimedia patient education about medications would most likely be used as an adjunct to, rather than a replacement of, patient education provided by a health professional as part of usual care. Multimedia education was shown to be more effective at improving patient knowledge and skill acquisition when compared with no education or non‐standardised education provided by health professionals as part of usual care. However, only two studies examined the addition of multimedia education to standardised education by a health professional and compared it to education by a health professional alone. Results from the studies were inconclusive, with Solomon 1988 reporting a large increase in knowledge as well as increased compliance in the group which received the multimedia education program, while Kinnane 2008 reported no difference in knowledge between the two groups. The variability in results may be due to differences in the quality of the education provided by the health professionals. In Solomon 1988 both groups received standardised verbal instructions from their doctor consisting of a short paragraph outlining proper use of the medication. In Kinnane 2008 the patients received much more intensive education from a health professional, consisting of a detailed, one‐hour standardised education session from a registered nurse as well as written information about the medication and management of side effects.

This review found that multimedia education had no greater effect on medication compliance than usual care or no education. This is in keeping with previous studies and reviews that have found that improving patient education does not necessarily lead to improved rates of compliance (Brus 1998; Cote 1997). As previously discussed, the concept of compliance assumes that patients play a passive role in accepting medical direction. The degree of intentional and rational non‐compliance with medications suggests that this is not the case (Lowe 2000). The patient’s role in decision‐making is acknowledged in the concept of concordance, where patients and health professionals work together to reach consensus decisions about the patient’s care (Stevenson 2004). None of the studies included in the review measured concordance.

The development and production of multimedia programs is expensive, especially when this is compared to the limited cost involved in producing written information leaflets. None of the studies in this review evaluated the cost‐effectiveness of multimedia education. Only two studies measured resource utilisation. Stone 1989 reported the amount of time required to deliver the educational intervention (multimedia education 17.6 minutes compared with nurse lecture 26 minutes (SD 5.7)) and reported no difference in the time needed for questions following the intervention between the two groups. Kinnane 2008 measured the number and content of telephone calls from patients to the outpatient clinic during the study period and reported no difference in the number of calls made by the multimedia education and control groups, but noted that calls made by the multimedia education group were more likely to be about medical problems covered in the education program. Of the 22 multimedia programs used by the studies included in this review, only 6 were still available or could be obtained from the authors. It is not known how many of the programs evaluated in the studies are still in clinical use.

We could not extract data from several studies for meta‐analysis. The primary outcome of knowledge was not measured in two of the ten studies comparing multimedia education to usual care or no education and data could not be extracted from a further study. Three of the seven studies comparing multimedia education to written information or education by a health professional measured knowledge. Data could only be extracted from two of these studies and the results could not be pooled. Two of the three studies comparing multimedia education to a control multimedia program reported results for patient knowledge in a form that could be extracted for meta‐analysis. One of the five studies comparing multimedia education with a co‐intervention to the co‐intervention alone did not measure knowledge, and in a further two studies, data could not be extracted for this outcome. The other primary outcome of skill acquisition was measured in 8 of the 24 studies. All of these studies measured inhaler technique and reported data suitable for meta‐analysis.

Limited conclusions based on single studies could be reached regarding the effect of multimedia education on other outcomes including patient satisfaction, self‐efficacy, quality of life, medication side effects and health outcomes. Our capacity to pool information from studies was limited due to heterogeneity in the comparisons used, the outcomes measured and the instruments used to measure them. A number of studies did not report data in a format suitable for meta‐analysis. One of the secondary objectives of this review was to examine whether the effects of multimedia education persisted over time. Five of the included studies measured outcomes at one month after the intervention and five studies measured outcomes beyond one month (six weeks to nine months). We discussed the results of these studies at different time points in Effects of interventions but, due to the heterogeneity of study outcomes and comparators, we could not provide an overall assessment of the persistence of multimedia education effects over time.

Quality of the evidence

Many of the studies did not report sufficient information in their methods to allow judgment of their risk of bias. From the information that was reported, three of the studies had a high risk of selection bias, and one was at high risk of assessments being biased due to lack of blinding of the outcome assessors. The quality of the evidence is outlined below for each of the comparison groups.

Multimedia education compared with usual care or no education

Conclusions regarding the superior effect of multimedia education on knowledge were based on the results from six studies containing 817 participants. The evidence was downgraded to low quality due to the studies having an unclear risk of bias for allocation concealment, blinding of outcome assessors or both, and due to considerable statistical heterogeneity (I² = 89%). Results from all of the studies included in the meta‐analysis favoured the multimedia education group, although the confidence interval for one of the studies crossed zero. We extracted dichotomous data from a further study of 167 participants, but these were not combined with continuous data from the other studies. The evidence from this study was also downgraded to low quality due to the results being based on a single study with unclear risk of bias for allocation concealment and blinding of outcome assessors. However, the results from this study showed a consistent effect favouring multimedia education, despite methodological limitations which may have biased the results in favour of the control group.

Conclusions regarding the superior effect of multimedia education on skill acquisition were based on data from two studies with 94 participants. Two studies containing a total of 4552 participants provided evidence that multimedia education was not effective in improving patient compliance with medications. The quality of the evidence for both of these outcomes was downgraded to moderate due to unclear risk of bias.

Conclusions for post‐operative pain, risk of drug misuse and dependence, self‐efficacy for medication adherence and for avoiding interactions with prescribed medications were based on single studies of varying size (43 to 343 participants). All of these outcomes, apart from post‐operative pain, were downgraded to low quality of evidence, due to conclusions being drawn from a single study with unclear risk of bias. The quality of the post‐operative pain outcome was downgraded to very low, as the study was at high risk of bias due to lack of allocation concealment.

Multimedia compared with other forms of education

The equivalent effect of multimedia education compared with written education on knowledge was based on very low quality evidence. The conclusion was based on a single study of 162 participants. The study had unclear risk of bias for both allocation concealment and blinding of outcome assessors and had methodological limitations which may have biased the results in favour of written education. A further study with 101 participants also reported no difference in effect, but data could not be extracted to verify this result. The superior effect of multimedia education compared with written education on skill acquisition was based on 3 studies with 184 participants. Dichotomous data were pooled from two of the studies while continuous data from the third study were reported separately. The three studies provided low to moderate quality evidence and all had unclear risk of bias for allocation concealment and or blinding of outcome assessors.

The equivalent effect of multimedia education compared with education by a health professional on knowledge was based on very low quality evidence. The conclusion was based on a single study of 22 participants which was at high risk of bias due to lack of allocation concealment. The effect of multimedia education compared with education by a health professional on skill acquisition was based on 4 studies with 245 participants. Data were pooled for three studies measuring skill acquisition within four weeks of the intervention (N = 130) and two studies measuring this outcome four weeks or more after the intervention (N = 130). Within four weeks, multimedia education was equivalent to education by a health professional, but there was significant heterogeneity in the results of the studies. This may be explained by differences in the amount of education received by the control group. Two of the studies had unclear risk of bias for allocation concealment and blinding of outcome assessors. When skill acquisition was measured at four weeks or more, the results were also equivalent. However, the 95% CI was wide and included both no effect and a substantial effect in the direction of the control group.

The equivalent effect of multimedia education on skill acquisition when compared with the combination of written education and education by a health professional was based on a single study of 69 participants. The quality of the evidence was downgraded to very low due to the single study having unclear risk of bias for allocation concealment, and the wide 95% CI crossing zero and including both no effect and a moderate sized effect favouring the multimedia education.

Multimedia education compared with a control multimedia program

The equivalent effect of multimedia education on knowledge when compared with a control multimedia program was based on 2 studies with 568 participants. The evidence was of moderate quality and was downgraded due to unclear risk of bias for allocation concealment. Conclusions regarding the superior effect of multimedia education on skill acquisition, medication compliance, self‐efficacy and peak expiratory flow readings were all based on single studies. The evidence for the effect on self‐efficacy was of moderate quality, and was only downgraded because it was based on a single study. The quality of the evidence for the other outcomes was further downgraded to low. The results for compliance may have been confounded by higher levels of baseline compliance in the intervention group. Conclusions for other outcomes were based on studies with unclear risk of bias for allocation concealment. Conclusions regarding the effect on quality of life were based on a single study of 269 participants. The 95% CI crossed zero and included both no effect and a small to moderate sized effect favouring the multimedia education.

Multimedia education with a co‐intervention compared with the co‐intervention alone

Conclusions regarding the superior effect of the addition of multimedia education to a co‐intervention on knowledge was based on the results of 2 studies with 381 participants. The evidence was of moderate quality and was downgraded due to the studies having unclear risk of bias for allocation concealment. The lack of effect on skill acquisition of the addition of multimedia education to written education was based on a single study of 87 participants. The evidence was of very low quality due to the single study having unclear risk of bias for allocation concealment and due to a wide 95% CI that included both no effect and substantial effect in the direction of the multimedia group. The results were inconsistent with findings from other studies that used written education as a comparator. The study showed that multimedia education was more effective than written education when the outcome was measured immediately following the intervention (MD 13.10, 95% CI 6.16 to 20.04). However, this effect was not maintained at two weeks which is the time point extracted for meta‐analysis. The study used healthy volunteers rather than patients and the study authors postulated that the deterioration in inhaler technique scores over the two weeks may have been because the volunteers, unlike asthma patients, were not using the inhalers between the two time points.

Conclusions for the superior effect of multimedia education on self‐efficacy was based on a single study with 60 participants. Conclusions for the lack of effect of the addition of multimedia education on medical complications from the underlying illness and medication side effects were based on single studies. The evidence was downgraded to low or very low due to study limitations including unclear risk of bias, wide 95% CI or indirect measurement of the outcome. Medication compliance was measured in 2 studies with 397 participants. However, results were not pooled as dichotomous data were reported for one study and continuous data for the other. There was an inconsistent effect of multimedia education on medication compliance, with one study showing better compliance in the multimedia education group while the other study reported no difference. The quality of the evidence for both studies was low due to unclear risk of bias for allocation concealment or a wide 95% CI that included both no effect and a substantial effect favouring multimedia education .

Limitations of the review

Heterogeneity in the content and quality of the comparators

In order to evaluate whether multimedia delivery of education is effective compared with existing forms of patient education, it is important that the educational content provided to participants is similar in both the intervention and control arms. However, in a number of studies, this was not the case.

This review provides evidence that multimedia education about medications is superior to usual care or no education in improving patient knowledge and skill acquisition. However, the effect of multimedia education may have been overestimated by the design of some of the studies. Three of the ten studies comparing multimedia education to usual care or no education required patients to have taken the medication for a certain period of time in order to be eligible to participate in the study (Mazor 2007; Navarre 2007; Van Der Palen 1997). This resulted in a patient group which had started the medication, and probably received education about the medication, months to years before being enrolled in the study. The control groups did not receive any information about the medication as part of the study and were compared to the multimedia group who received education about the medication a short time before outcomes were measured. A fourth study (Neafsey 2001) reported a large effect size in the multimedia education group due to extremely low levels of knowledge in the control group who were unlikely to have received any information about the area of knowledge being tested.

Eight studies used written educational materials in the control arm. In five studies, the written materials were directly compared to multimedia education (Goodyer 2006; Olver 2009; Savage 2003; Schnellinger 2010; Self 1983), while in three studies, they were used as a co‐intervention (McElnay 1989; Neafsey 2002; Osguthorpe 1983). The information provided in the written educational materials was similar to that in the multimedia intervention in all of the studies. Nine studies used standardised education by a health professional in the control arm. In six studies, education by a health professional was compared directly to multimedia education (Goodyer 2006; Lirsac 1991; McElnay 1989; Self 1983; Stone 1989; Van Der Palen 1997), while in three studies it was used as a co‐intervention (Kinnane 2008; Solomon 1988; Trent 2010). There was marked variability in the content of the standardised education provided by health professionals and its similarity to the information provided in the multimedia intervention. Five of the six studies comparing education by a health professional to multimedia education provided information about MDIs. In four of the studies, the control arm received direct instruction from a health professional, either individually or in a group setting. This instruction included the health professional demonstrating correct inhaler technique and, in at least two of the studies, viewing patients' inhaler technique and correcting errors. However, in Lirsac 1991 the health professional only read out instructions for correct technique while the participant looked at illustrations. The participants were not shown a demonstration. In the remaining study (Stone 1989), the control arm received a 25‐minute lecture about anticoagulant therapy with identical content to the multimedia program. The education provided by health professionals as a co‐intervention also varied. In Kinnane 2008, the patients received a one‐hour standardised education session from a registered nurse while in Trent 2010, all participants received detailed discharge instructions. However, in Solomon 1988, the verbal instructions consisted only of a single paragraph stating the name of the medication and instructions on how to take the medication correctly. This variability in the comparators may account for the heterogeneity of results seen when comparing multimedia education to standardised education by a health professional. Overall, the results suggest that multimedia education is superior to brief standardised education provided by a health professional but not to more intensive interventions where the health professional provides the same or similar information to what is included in the multimedia program. Multimedia education may still be preferable and more practical in these situations due to the time required to provide the more intensive interventions.

The quality of the comparator could only be evaluated in 4 of the 16 studies which compared multimedia to another form of education, We obtained a copy of the printed information leaflet used as the comparator in three studies (Goodyer 2006; McElnay 1989; Savage 2003), allowing complete evaluation of its quality. Solomon 1988 published the transcript of the standardised verbal instructions provided by health professionals, also allowing for evaluation of its quality. For a further four studies, we performed a limited evaluation based on a description of the education provided in the study publication.

Heterogeneity in the content and quality of the multimedia interventions

Heterogeneity in the content and quality of the multimedia educational interventions may also explain some of the variability of results in the review. However, our ability to evaluate the educational interventions was limited by the paucity of information reported by the study authors. We intended to determine an overall grading of the quality of the educational interventions and comparators based upon our application of the Evaluative Linguistic Framework (ELF). This was not performed as quality could only be fully evaluated for the six studies for which the multimedia intervention was available and provided by the study authors (Deitz 2011; Kinnane 2008; Mazor 2007; Navarre 2007; Olver 2009; Trent 2010). For the another seven studies, we performed a limited evaluation based on the voice‐over script (Goodyer 2006; Savage 2003; Schwarz 2008a; Voris 1982) or descriptions of the multimedia program (Kato 2008; Neafsey 2001; Neafsey 2002). Only 2 of 16 studies that compared multimedia to a different form of education provided enough information to allow assessment of both the multimedia and comparison educational interventions (Goodyer 2006; Savage 2003). The remaining 11 studies provided insufficient information on which to base an assessment of the quality of the intervention.

Although the ELF was a useful starting point for evaluating the quality of the educational interventions, it was designed to evaluate written materials, and does not capture many aspects of multimedia interventions. We could assess the generic structure for the multimedia programs used in 18 of the studies. None of the programs contained all ten of the possible moves (sections of information) identified by the ELF. However, the number of moves included varied based on the aims of the program, and therefore did not necessarily reflect program quality. For example, three programs included only one move ('dosage instructions'). However, this was appropriate as the programs focused on instructing patients on the correct use of MDIs. We calculated lexical density for nine of the programs and this varied from 29% to 65%. The lowest lexical density was found in programs or sections of programs that depicted patients presenting information or having a conversation (29% to 36%). This degree of lexical density is in keeping with that seen in natural speech and informal text (Halliday 1985). The lexical density in the other programs, where the information was presented by a health professional or narrator, varied from 42% to 65%. This is in keeping with the lexical density seen in formal or technical texts (Halliday 1985) raising the possibility that the information, when presented as text, would be difficult for patients to understand. However, presentation of this information as a voice‐over may overcome this difficulty.

Outcome measures

The heterogeneity in the outcomes reported and the instruments used to measure these outcomes, and the lack of data regarding the minimum clinically important difference for the outcomes, limited the conclusions that could be drawn from this review. Instruments used to measure outcomes were often developed by the study authors with limited reporting of their reliability and validity. Fourteen of the 15 studies that measured patient knowledge used scales developed by the study authors for the purpose of the study or similar preceding studies. The other scale had previously been used in a telephone survey about emergency contraception. Of these 15 studies, 2 reported measures of scale reliability such as internal consistency or test‐retest reliability. Six reported that the scale was pilot tested with the target population and three reported content validity based on expert review. Only one study reported testing discriminant validity of the scale. The use of scales which have undergone limited testing of their measurement properties raises the possibility that a lack of effect may be due to the scale being insensitive to change, rather than inefficacy of the intervention. This was particularly evident in Schnellinger 2010 where the results from the knowledge scale were skewed to the left, and 23% of participants had perfect scores at baseline. This suggests that the scale was insensitive to change due to a ceiling effect, and poorly targeted to knowledge in the sample population.

Potential biases in the review process

The broad search strategy used in this review minimised the risk of missing relevant studies. The success of the search strategy in capturing relevant literature was supported by the lack of further studies being identified for inclusion when reference lists from included studies and relevant reviews were examined. Screening of titles, abstracts and the full text of studies to identify those meeting the inclusion criteria. as well as data extraction from the included studies were performed independently by two review authors, minimising the risk of bias and errors. Sensitivity analyses showed that imputation of missing SDs did not change the results of the meta‐analyses, and results did not differ with the use of random‐effects or fixed‐effect models, suggesting that results of meta‐analyses were robust and not being biased by the chosen methodology.

We extracted post‐intervention outcome data and used them for the meta‐analyses without any statistical adjustment for pre‐intervention scores. For most of the studies this would not have led to bias in the results, due to randomisation resulting in similar baseline scores. However, in some cases the results of the meta‐analysis conflicted with results reported by study authors that were calculated using statistical methods that incorporated change over time or adjusted for baseline scores. For example, Kato 2008 reported no statistically‐significant difference in compliance between the intervention and control groups when using a repeated‐measures mixed‐effect linear model that tested differences between treatment groups at the three measured time points. The use of unadjusted means from the three‐month time point for the meta‐analysis favoured multimedia, but may have been confounded by higher levels of baseline compliance in the multimedia group. All cases where the meta‐analysis findings conflicted with those of the study authors were reported either in the text of the review or in the accompanying tables.

Agreements and disagreements with other studies or reviews

This review provides more conclusive evidence for the effectiveness of multimedia education about medications in improving patient knowledge and skill acquisition than previous reviews in this area (Jeste 2008; Wofford 2005). The results from Jeste 2008 were inconclusive, with four of the eight studies finding that multimedia education about medications was superior to the comparator in improving patient knowledge. Wofford 2005 did not provide a synthesis of the effectiveness of multimedia interventions due to variability in the topics of the educational interventions and the reported outcome measures in the included studies. We also found that there was variability in the outcomes measured and reported by the included studies, and that this limited conclusions about the effectiveness of multimedia education on outcomes other than knowledge and skill acquisition.

The inclusion criteria for our review differed from previous reviews of multimedia education, in that it focused only on purely educational interventions about prescription and over‐the‐counter medications, where the effect of the multimedia educational component on outcomes could be separated from the effect of other components of the intervention. Unlike previous reviews, this review did not place any restrictions on the language in which the study was published, the age of participants, the method used to deliver the multimedia program or the outcomes measured. Twenty of the 24 studies included in this review had not been included in either of the previous reviews.

The results from this review differed from the finding in Ryan 2011 that there was insufficient evidence that education alone improves knowledge about medications. However, the results from this review are consistent with the finding from Haynes 2008 and Ryan 2011 that education alone is ineffective at improving medication compliance.

Figure 1

Study flow diagram.

Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Figure 3

Forest plot of comparison: 1 Multimedia education versus usual care or no education, outcome: 1.1 Knowledge (mean score, %).

Figure 4

Forest plot of comparison: 2 Multimedia education versus written education, outcome: 2.3 Skill acquisition (N who improved).

Figure 5

Forest plot of comparison: 3 Multimedia education versus education by a health professional, outcome: 3.2 Skill acquisition (mean score, %).

Figure 6

Forest plot of comparison: 5 Multimedia education versus control multimedia, outcome: 5.1 Knowledge (mean score, %).

Figure 7

Forest plot of comparison: 6 Mulitmedia education and a co‐intervention versus co‐intervention alone, outcome: 6.1 Knowledge (mean score, %).

Analysis 1.1

Comparison 1 Multimedia education versus usual care or no education, Outcome 1 Knowledge (mean score, %).

Analysis 1.2

Comparison 1 Multimedia education versus usual care or no education, Outcome 2 Knowledge (N who improved).

Analysis 1.3

Comparison 1 Multimedia education versus usual care or no education, Outcome 3 Skill acquisition (mean score, %).

Analysis 1.4

Comparison 1 Multimedia education versus usual care or no education, Outcome 4 Compliance with medication (% who complied).

Analysis 1.5

Comparison 1 Multimedia education versus usual care or no education, Outcome 5 Compliance with monitoring (% who complied).

Analysis 1.6

Comparison 1 Multimedia education versus usual care or no education, Outcome 6 Pain rating (mean score, range 0 to 10).

Analysis 1.7

Comparison 1 Multimedia education versus usual care or no education, Outcome 7 Risk of drug abuse (mean score).

Analysis 1.8

Comparison 1 Multimedia education versus usual care or no education, Outcome 8 Satisfaction with care (mean score).

Analysis 1.9

Comparison 1 Multimedia education versus usual care or no education, Outcome 9 Perception of care (mean score).

Analysis 1.10

Comparison 1 Multimedia education versus usual care or no education, Outcome 10 Self‐efficacy (mean score).

Analysis 1.11

Comparison 1 Multimedia education versus usual care or no education, Outcome 11 Beliefs about medication (mean score, range 1 to 5).

Analysis 1.12

Comparison 1 Multimedia education versus usual care or no education, Outcome 12 Beliefs about medication (N who answered correctly).

Analysis 1.13

Comparison 1 Multimedia education versus usual care or no education, Outcome 13 Perception of the education (N who learnt something new).

Analysis 2.1

Comparison 2 Multimedia education versus written education, Outcome 1 Knowledge (N who improved).

Analysis 2.2

Comparison 2 Multimedia education versus written education, Outcome 2 Skill acquisition (mean score, %).

Analysis 2.3

Comparison 2 Multimedia education versus written education, Outcome 3 Skill acquisition (N who improved).

Analysis 2.4

Comparison 2 Multimedia education versus written education, Outcome 4 Beliefs about medication (N who would not inappropriately request Rx).

Analysis 2.5

Comparison 2 Multimedia education versus written education, Outcome 5 Perception of the education (N who learnt something new).

Analysis 3.1

Comparison 3 Multimedia education versus education by a health professional, Outcome 1 Knowledge (mean score, %).

Analysis 3.2

Comparison 3 Multimedia education versus education by a health professional, Outcome 2 Skill acquisition (mean score, %).

Analysis 3.3

Comparison 3 Multimedia education versus education by a health professional, Outcome 3 Bronchial obstruction (FEV, litres).

Analysis 4.1

Comparison 4 Multimedia education versus written education and education by a health professional, Outcome 1 Skill acquisition (N who improved).

Analysis 5.1

Comparison 5 Multimedia education versus control multimedia, Outcome 1 Knowledge (mean score, %).

Analysis 5.2

Comparison 5 Multimedia education versus control multimedia, Outcome 2 Skill acquisition (mean change score, %).

Analysis 5.3

Comparison 5 Multimedia education versus control multimedia, Outcome 3 Compliance with medication (mean score, range 18‐90).

Analysis 5.4

Comparison 5 Multimedia education versus control multimedia, Outcome 4 Use of medication (N who used medication).

Analysis 5.5

Comparison 5 Multimedia education versus control multimedia, Outcome 5 Peak flow reading (litres per second).

Analysis 5.6

Comparison 5 Multimedia education versus control multimedia, Outcome 6 Self‐efficacy (mean score, range 27 to 189).

Analysis 5.7

Comparison 5 Multimedia education versus control multimedia, Outcome 7 Quality of life (mean score).

Analysis 5.8

Comparison 5 Multimedia education versus control multimedia, Outcome 8 Beliefs about medication (N with more positive beliefs).

Analysis 5.9

Comparison 5 Multimedia education versus control multimedia, Outcome 9 Perceived stress (mean score, range 10 to 50).

Analysis 6.1

Comparison 6 Mulitmedia education and a co‐intervention versus co‐intervention alone, Outcome 1 Knowledge (mean score, %).

Analysis 6.2

Comparison 6 Mulitmedia education and a co‐intervention versus co‐intervention alone, Outcome 2 Skill acquisition (mean score, %).

Analysis 6.3

Comparison 6 Mulitmedia education and a co‐intervention versus co‐intervention alone, Outcome 3 Non‐compliance (mean score, range 0 to 160).

Analysis 6.4

Comparison 6 Mulitmedia education and a co‐intervention versus co‐intervention alone, Outcome 4 Compliance with medication (N).

Analysis 6.5

Comparison 6 Mulitmedia education and a co‐intervention versus co‐intervention alone, Outcome 5 Compliance with follow‐up (N).

Analysis 6.6

Comparison 6 Mulitmedia education and a co‐intervention versus co‐intervention alone, Outcome 6 Medical complication (N).

Analysis 6.7

Comparison 6 Mulitmedia education and a co‐intervention versus co‐intervention alone, Outcome 7 Adverse medication behaviour (mean score, range 0‐40).

Analysis 6.8

Comparison 6 Mulitmedia education and a co‐intervention versus co‐intervention alone, Outcome 8 Self‐efficacy (mean score, range 0 to 5).

Summary of findings for the main comparison. Summary of findings: multimedia education compared with no education or usual care

Multimedia education compared with no education or usual care for prescribed and over‐the‐counter medications
Patient or population: patients taking prescribed and over‐the‐counter medications or their carers Intervention: multimedia education Comparison: no education or usual care
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	no education or usual care	multimedia education
Knowledge (< 4 weeks) Mean number of correct responses (higher score indicates higher knowledge) Follow‐up: 0 to 3 weeks		The mean knowledge (< 4 weeks) in the intervention groups was 1.04 higher (0.49 to 1.58 higher)		817 (6 studies)	++OO low^a,b	Standardised score used as one study (Deitz 2011) did not provide a denominator and therefore could not be converted to the same scale as the other studies. A standard deviation of 1.04 represents a large difference between groups. 1 further study of 167 patients measured the number whose knowledge score improved and found that this was 458 versus 202 per 1000 in the intervention and control groups respectively (RR 2.26, 95% CI 1.39 to 3.67). The quality of the evidence was low^a,c. 1 study with 8 patients measured mean knowledge (%) at 4 weeks or more and found it was 22.5 higher (0.42 lower to 45.42 higher) in the intervention group. The quality of the evidence was very low^a,c,d.
Skill acquisition Mean inhaler technique score (%), higher score indicates better technique. Scale from: 0 to 100. Follow‐up: 0 to 9 months	The mean skill acquisition in the control groups was 71.22%^e	The mean skill acquisition in the intervention groups was 18.32 higher (11.92 to 24.73 higher)		94 (2 studies)	+++O moderate^a
Compliance with medication (different measures used by the studies: patient self‐report of compliance and prescription refill data). Follow‐up: 3 to 39 weeks	Low risk population^f		RR 1.02 (0.96 to 1.08)	4552 (2 studies)	+++O moderate^a
	443 per 1000	452 per 1000 (425 to 478)
	Medium risk population^f
	704 per 1000	718 per 1000 (676 to 760)
	High risk population^f
	965 per 1000	984 per 1000 (926 to 1000)
Health outcomes: Drug misuse and dependence CAGE screening tool. Scale from 0 to 4. Higher score indicates greater probability of drug misuse or dependence	The mean CAGE score in the control group was 0.86	The mean CAGE score in the intervention group was 0.38 lower (0.60 lower to 0.15 lower)		329 (1 study)	++OO low^a,c	1 further study with 43 participants measure pain on a scale of 0 (no pain) to 10 (worst possible pain) and found that pain in the intervention group was 0.5 lower (1.44 lower to 0.44 higher). However, the quality of evidence was very low^c,g.
Medication side effects ‐ not measured	See comment	See comment	Not estimable	‐	See comment	One study measured medication side effects but did not report results in a form that could be extracted for meta‐analysis. The authors reported no statistically‐significant difference in the incidence of side effects between the two groups.
Quality of life ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured quality of life.
Self‐efficacy Self‐efficacy for medication adherence (higher score indicates greater self‐efficacy, scale not reported)	The mean self‐efficacy in the control group was 56.88	The mean self‐efficacy in the intervention group was 1.94 higher (0.56 lower to 4.44 higher)		343 (1 study)	++OO low^a,c	1 further study with 99 patients measured self‐efficacy for avoiding drug interactions (scale of 1 to 5) and found that mean self‐efficacy in the intervention groups was 1.38 higher (0.9 to 1.86 higher). The quality of the evidence was low^a,c.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk Ratio; SMD: Standardised Mean Difference
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
a. All of the studies had unclear risk of bias for allocation concealment, blinding of outcome assessors or both. b. Considerable statistical heterogeneity (I² = 89%). However, all but one of the studies (Deitz 2011) favoured the multimedia group. Heterogeneity may be due to variability in the education provided to the control group as part of usual care. c. Results are from only one study. d. Wide 95% confidence interval including both no effect and substantial effect in the direction of the intervention group. e. Control groups results measured at the same time point as was used in the meta‐analysis were used to calculate mean scores across the included studies. f. Three assumed baseline risks were provided based on the control group risks in the included studies (low and high risk) and the median risk across the two studies (medium). g. The study was at high risk of bias due to lack of allocation concealment.

Summary of findings for the main comparison. Summary of findings: multimedia education compared with no education or usual care

Summary of findings 2. Summary of findings: multimedia education compared with written education

Multimedia education compared with written education for prescribed and over‐the‐counter medications
Patient or population: patients taking prescribed and over‐the‐counter medications or their carers Intervention: multimedia education Comparison: written education
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	written education	multimedia education
Knowledge (number whose knowledge score improved) Follow‐up: one day	570 per 1000^a	458 per 1000 (336 to 621)	RR 0.80 (0.59 to 1.09)	162 (1 study)	+OOO very low^b,c	More patients had perfect scores at baseline in the multimedia group (241 versus 165 per 1000). Improvement could not be detected in these patients which may have biased results in favour of written education.
Number who improved on skill (global inhaler technique rating) Follow‐up: mean one hour	Low risk population^d		RR 2.14 (1.33 to 3.44)	164 (2 studies)	+++O moderate^e	1 further study with 20 participants reported that mean inhaler technique score (%) was 31 higher (10.15 to 51.85 higher) in the intervention group. The quality of the evidence was low^b,c.
	180 per 1000	385 per 1000 (239 to 619)
	Medium risk population^d
	222 per 1000	475 per 1000 (295 to 764)
	High risk population^d
	260 per 1000	556 per 1000 (346 to 894)
Compliance with medication	See comment	See comment	Not estimable	‐	See comment	No studies measured compliance with medication.
Health outcomes ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured health outcomes.
Medication side effects ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured medication side effects.
Quality of life ‐ not measured	See comment	See comment		‐	See comment	No studies measured quality of life.
Self‐efficacy ‐ not measured	See comment	See comment		‐	See comment	No studies measured self‐efficacy.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk Ratio
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
a. The assumed risk was calculated from the mean baseline risk in the single study included in the meta‐analysis. b. The study had unclear risk of bias for allocation concealment and blinding of outcome assessors. c. Results are from only one study. d. Three assumed baseline risks were provided based on the control group risks in the included studies (low and high risk) and the median risk across the two studies (medium). e. Studies had unclear risk of bias for allocation concealment.

Summary of findings 2. Summary of findings: multimedia education compared with written education

Summary of findings 3. Summary of findings: multimedia education compared with education by a health professional

Multimedia education compared with education by a health professional for prescribed and over‐the‐counter medications
Patient or population: patients taking prescribed and over‐the‐counter medications or their carers Intervention: multimedia education Comparison: education by a health professional
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	education by a health professional	multimedia education
Knowledge Mean number of correct responses (%). Scale from: 0 to 100. Follow‐up: mean 1 day	The mean knowledge in the control groups was 88.9 %^a	The mean knowledge in the intervention groups was 2.2 lower (8.83 lower to 4.43 higher)		22 (1 study)	+OOO very low^b,c
Skill acquisition (< 4 weeks) Mean inhaler technique score (%), higher score indicates better technique. Scale from: 0 to 100. Follow‐up: 0 to 2 weeks	The mean skill acquisition (< 4 weeks) in the control groups was 76.7%^a	The mean skill acquisition (< 4 weeks) in the intervention groups was 1.01 lower (15.75 lower to 13.72 higher)		130 (3 studies)	+OOO very low^d,e,f	Two studies with 130 patients reported skill acquisition at 4 weeks of more and found that mean inhaler technique score (%) was 4.29 lower (17.23 lower to 8.65 higher) in the intervention group. The quality of the evidence was low^d,e.
Compliance with medication ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured compliance with medication.
Health outcomes Bronchial obstruction (FEV), higher score indicates less bronchial obstruction. Theoretical maximum scores were 2.72 for the multimedia and 3.14 for the control group. Follow‐up: 15 days	The mean FEV (at 15 days) in the control group was 2.09^a	The mean FEV (at 15 days) in the intervention group was 0.29 higher (0.26 lower to 0.84 higher)		28 (1 study)	+OOO very low^c,e,g
Medication side effects ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured medication side effects.
Quality of life ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured quality of life.
Self‐efficacy ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured self‐efficacy.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk Ratio; MD: Mean Difference; FEV: Forced Expiratory Volume
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
a. Control groups results measured at the same time point as was used in the meta‐analysis were used to calculate mean scores across the included studies. b. The study was at high risk of bias due to lack of allocation concealment. c. Results were based on one study with a small sample size and wide 95% confidence interval. d. All of the studies had unclear risk of bias for blinding of outcome assessors. All of the studies except Lirsac 1991 also had unclear risk of bias for allocation concealment. e. Wide 95% confidence interval including both no effect and substantial effect. f. Substantial statistical heterogeneity (I² = 68%) which may be due to differences in the education provided to the control group. g. The study had unclear risk of bias for blinding of outcome assessors.

Summary of findings 3. Summary of findings: multimedia education compared with education by a health professional

Summary of findings 4. Summary of findings: multimedia education compared with written education and education by a health professional

Multimedia education compared with written education and education by a health professional for prescribed and over‐the‐counter medications
Patient or population: patients taking prescribed and over‐the‐counter medications or their carers Intervention: multimedia education Comparison: written education and education by a health professional
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	written education and education by a health professional	multimedia education
Knowledge ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured knowledge.
Compliance with medication ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured compliance with medication.
Number who improved on skill (rating of inhaler technique) Follow‐up: mean 1 day	429 per 1000^a	502 per 1000 (300 to 832)	RR 1.17 (0.7 to 1.94)	69 (1 study)	+OOO very low^b,c
Health outcomes ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured health outcomes.
Medication side effects ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured medication side effects.
Quality of life ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured quality of life.
Self‐efficacy ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured self‐efficacy.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk Ratio
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
a. The assumed risk was calculated from the mean baseline risk in the single study included in the meta‐analysis. b. The study had unclear risk of bias for allocation concealment. c. Results were based on a single study with a relatively small sample size and wide confidence interval.

Summary of findings 4. Summary of findings: multimedia education compared with written education and education by a health professional

Summary of findings 5. Summary of findings: multimedia education compared with control multimedia

Multimedia education compared with control multimedia for prescribed and over‐the‐counter medications
Patient or population: patients taking prescribed and over‐the‐counter medications or their carers Intervention: multimedia education Comparison: control multimedia
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	control multimedia	multimedia education
Knowledge Mean number of correct responses (%). Scale from: 0 to 100. Follow‐up: 3 to 6 months	The mean knowledge in the control groups was 61%^a	The mean knowledge in the intervention groups was 2.78 higher (1.48 lower to 7.05 higher)		568 (2 studies)	+++O moderate^b
Skill acquisition Inhaler technique (scored 0 to 100 and reported as change in score from baseline) Follow‐up: 1 month	The mean change in inhaler technique score in the control group was 1.62 out of 100^a	The mean change in inhaler technique score in the intervention group was 13.3 higher (8.98 to 17.62 higher)		116 (1 study)	++OO low^b,c	Data from the last time point at which the outcome was measured included in the 'Summary of findings' table.
Compliance with medication. Mean score of the Chronic Disease Compliance Instrument (CDCI), higher score indicates better compliance. Scale from: 18 to 90. Follow‐up: 3 months	The mean compliance with medication in the control groups was 78.4 out of 90^a	The mean compliance with medication in the intervention groups was 2.6 higher (0.78 to 4.42 higher)		303 (1 study)	++OO low^c,e
Health outcomes Peak expiratory flow readings (higher readings indicate better peak flow) Follow‐up: 1 day	The mean peak flow in the control group was 382^d	The mean peak flow in the intervention group was 21 higher (5.28 to 37.20 higher)		116 (1 study)	++OO low^b,c
Medication side effects ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured medication side effects
Quality of life (QOL). Outcome was measured on different scales in different studies (higher score indicates better QOL) Follow‐up: mean 3 months		The mean quality of life in the intervention groups was 0.2 higher (0.04 lower to 0.44 higher)		269 (1 study)	+++O moderate^c	A standard deviation of 0.2 represents a small difference between groups. SMD 0.2 (‐0.04 to 0.44)
Self‐efficacy. Self efficacy score (higher score indicates greater self‐efficacy). Scale from: 27 to 189. Follow‐up: mean 3 months	The mean self‐efficacy in the control groups was 158.8 out of 189^a	The mean self‐efficacy in the intervention groups was 5.3 higher (0 to 10.6 higher)		303 (1 study)	+++O moderate^c
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk Ratio; SMD: Standardised Mean Difference
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
a. Control groups results measured at the same time point as was used in the meta‐analysis were used to calculate mean scores across the included studies. b. One or more of the studies had unclear risk of bias for allocation concealment. c. Results are based on only one study. d. The assumed risk was calculated from the mean baseline risk in the single study included in the meta‐analysis. e. Baseline compliance levels were higher in the intervention group.

Summary of findings 5. Summary of findings: multimedia education compared with control multimedia

Summary of findings 6. Summary of findings: multimedia education and a co‐intervention compared with co‐intervention alone

Multimedia education and a co‐intervention compared with the co‐intervention alone for prescribed and over‐the‐counter medications
Patient or population: patients taking prescribed and over‐the‐counter medications or their carers Intervention: multimedia education and a co‐intervention Comparison: co‐intervention alone
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	co‐intervention alone	multimedia education and a co‐intervention
Knowledge (< 4 weeks) Mean number of correct responses (%). Scale from: 0 to 100. Follow‐up: 2 to 14 days	The mean knowledge (< 4 weeks) in the control groups was 68.76%^a	The mean knowledge (< 4 weeks) in the intervention groups was 24.59 higher (22.34 to 26.83 higher)		381 (2 studies)	+++O moderate^b	1 study with 60 patients measured mean knowledge (%) at 4 weeks or more and found it was 23.3 higher (12.82 to 33.58 higher) in the intervention group. The quality of the evidence was low^b,c.
Skill acquisition Mean inhaler technique score (%), higher score indicates better technique. Scale from: 0 to 100. Follow‐up: mean 2 weeks	The mean skill acquisition in the control groups was 59.1%^a	The mean skill acquisition in the intervention groups was 3.4 higher (8.3 lower to 15.1 higher)		87 (1 study)	+OOO very low^b,c,d
Non‐compliance with medications score Mean non‐compliance score (lower scores indicate better compliance). Scale from: 0 to 160. Follow‐up: 2 to 6 days	The mean non‐compliance score in the control groups was 40.45 out of 160^a	The mean non‐compliance score in the intervention groups was 32.15 lower (51.13 to 13.17 lower)		320 (1 study)	++OO low^b,c	1 further study with 77 patients measured the number who completed their course of medications and found that this was 659 versus 639 per 1000 in the intervention and control groups respectively (RR 0.97, 95% CI 0.7 to 1.35). The quality of the evidence was low^c,d.
Health outcome (Number who had a medical complication of pelvic inflammatory disease) Follow‐up: two weeks	317 per 1000^e	361 per 1000 (193 to 675)	RR 1.14 (0.61 to 2.13)	77 (1 study)	++OO low^c,d
Medication side effects Mean adverse self‐medication behaviour score (lower scores indicate safer self‐medication behaviour). Scale from: 0 to 40. Follow‐up: mean 4 weeks	The mean medication side effects in the control groups was 21 out of 40^a	The mean medication side effects in the intervention groups was 5 lower (10.06 lower to 0.06 higher)		60 (1 study)	+OOO very low^b,c,f	Data from the last time point at which the outcome was measured included in the 'Summary of findings' table.
Quality of life ‐ not measured	See comment	See comment	Not estimable	‐	See comment	No studies measured quality of life
Self‐efficacy Self‐efficacy rating scale (higher score indicates greater self‐efficacy). Scale from: 1 to 5. Follow‐up: mean 4 weeks	The mean self‐efficacy in the control groups was 3 on 1‐5 rating scale^a	The mean self‐efficacy in the intervention groups was 0.9 higher (0.52 to 1.28 higher)		60 (1 study)	++OO low^b,c	Data from the last time point at which the outcome was measured included in the 'Summary of findings' table.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk Ratio
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
a. Control groups results measured at the same time point as was used in the meta‐analysis were used to calculate mean scores across the included studies. b. The studies had unclear risk of bias for allocation concealment. c. Results were based on only one study. d. Wide 95% confidence interval including both no effect and substantial effect in the direction of the multimedia group. e. The assumed risk was calculated from the mean baseline risk in the single study included in the meta‐analysis. f. Outcome measures patient behaviours that are likely to cause medication adverse effects rather than measuring medication adverse effects directly.

Summary of findings 6. Summary of findings: multimedia education and a co‐intervention compared with co‐intervention alone

Table 1. Framework for evaluating healthcare text based upon systemic functional linguistics

Item	Description	Assessment
Overall organisational or generic structure of the text	Series of stages or moves in a text (e.g. background on drug, dosage instructions, account of side effects)	What identifiable sections of text (moves) are present? Are all essential moves included? What is the sequence of moves and is this appropriate?
Rhetorical elements	The function of each move in relation to the reader (e.g. to define, instruct, inform)	What are the rhetorical functions of each move in relation to the reader? Are these clearly defined and appropriate? Is there clear guidance about what to do with the presented information? Are instructions clear about what action needs to be taken?
Relationship between writer and reader	Nature of the relationship between the writer and reader (e.g. medical expert to layperson; doctor to his/her patient)	Is it clear who the writer and intended audience is? Is the relationship between writer and reader clear and consistent? Is the person who is expected to take responsibility for any actions clear? Is the importance and/or urgency of the action made clear? How positive (encouraging, reassuring) is the tone?
Meta discourse	Description of the purpose/structure of the text	Is there a clear description of the purpose of the text?
Headings	Signposts in the text for the reader	Are headings present? If present, are they appropriate?
Technicality of vocabulary	The technicality of the medical terminology/other vocabulary that is used	How technical is the vocabulary that is used in the text? Is this appropriate?
Lexical density	Density of the content words in the text	What is the average content density of the text (percentage of content‐bearing words)? Is this appropriate?
Factual content of text	Facts included in the text	Is the factual information correct and up‐to‐date? Is the source of information provided? Is the quality and strength of the evidence discussed?
Format	Visual aspects such as layout, font size, style, use of visual material, etc.	What is the length, layout, font size and visual aspect of the document?

Table 1. Framework for evaluating healthcare text based upon systemic functional linguistics

Table 2. Study outcome data

Study	Study arms	Timing of follow‐up	N at follow‐up	Outcome	Results
Acosta 2009	Multimedia (I) vs control multimedia (C)	Immediately before (baseline) and after (post) the intervention and after one month.	I: 62 C: 54	Skill acquisition (inhaler technique)	Change in score (% correct) from baseline: Post intervention: I: 15.92 (SD 15.04), C: 1.16 (6.55), P < 0.001, mean difference 14.77, 95% CI 10.39 to 19.15. After 1 month: I: 14.92 (SD 15.49), C: 1.62 (SD 7.30) P < 0.001, mean difference 13.30 95% CI 8.74 to 17.86.
Acosta 2009	Multimedia (I) vs control multimedia (C)		I: 62 C: 54	Peak flow	Post intervention I: 403.45 (95% CI 392.40 ‐ 414.94), C: 382.21 (95% CI 370.42 ‐ 394.01). Results are "controlled for pre‐intervention peak flows". There was no significant difference in pre intervention peak flows readings (C: 409.81, I: 386.94, P = 0.18)
Deitz 2011	Multimedia (I) vs control (C)	After the intervention period	Total post‐test N = 346 I: 181 C: 165
			N (who completed the knowledge questionnaire) = 329	Knowledge of prescription drug use and dependency	Mean score (SD): Drug facts I: 13.23 (2.40), C: 12.84 (2.33), P = 0.025; Smart use I: 13.1 (1.63), C:12.9 (1.43), P = 0.457; Manage health I: 6.48 (0.96), C: 6.40 (0.89), P = 0.127. Maximum score for the scales was not reported.
			1. N = 345 2. N = 343 3. N = 342	Self efficacy: 1. Self‐efficacy in obtaining medical information and attention to their concerns from their doctor (PEPPI) 2. Medication adherence self‐efficacy (Medication Adherence Survey) 3. Self efficacy in managing medication problems (Ability to Manage Problems Survey)	1. Mean score (SD): I: 17.85 (4.33), C: 17.70 (4.30), P = 0.687. Maximum score for the scale was not reported. 2. Mean score (SD): I: 58.82 (11.88), C: 56.88 (11.72), P = 0.013. Maximum score for the scale was not reported. 3. Mean score (SD): I: 28.05 (3.99), C: 27.34 (3.83), P = 0.026. Maximum score for the scale was not reported.
			N = 345	Patients' perception of the therapeutic alliance with care givers and degree of satisfaction with treatment (Patient feedback survey)	Mean score (SD): I: 30.20 (5.81), C: 30.19 (5.05), P = 0.744. Maximum score for the scale was not reported.
			N = 344	Patients' perception of the degree of directive guidance (instructions on taking their medication properly) given by doctors and pharmacists (Purdue)	Mean score (SD): I: 17.27 (4.40), C: 17.01 (4.07), P = 0.749. Maximum score for the scale was not reported.
			N = 329	Patients' perception about their current drug use and whether it is problematic (CAGE)	Mean score (SD): I: 0.485 (0.83), C: 0.861 (1.19), P = 0.038. Maximum score for the scale was not reported.
			N = 344	Self reported drug taking for non‐medical purposes (sections of the NSDUH)	Odds ratio between intervention and control group (from logistic regression with pre‐intervention non‐medical use entered as a control variable): Non‐medical use of analgesics: OR 0.656, 95% CI 0.147 to 2.92, P = 0.579. Non‐medical use of sedatives: OR 1.41, 95% CI 0.50 to 3.97, P = 0.517. Non‐medical use of tranquillisers: OR 2.09, 95% CI 0.92 to 33.03, P = 0.132. Non‐medical use of stimulants: OR 6.47, 95% CI 0.426 to 98.13, P = 0.179.
Goodyer 2006	Multimedia (I) vs written and verbal (V) vs written (C)	Immediately before and after the intervention	I: 34 V: 35 C: 35	Skill acquisition (inhaler technique)	Change in global technique rating. Number who were: worse than baseline I: 5/34, V: 4/35, C: 5/35; same as baseline I: 12/34, V: 16/35, C: 18/35; better than baseline I: 17/34, V: 15/35, C: 9/35. Number who: check mouthpiece I: 16/34, V:11/35, C: 1/35; shake inhaler: I: 24/34, V: 35/35, C: 16/35; co‐ordination I: 11/34, V: 10/35, C: 3/35.
Kato 2008	Multimedia education (I) vs control multimedia (C)	Before the intervention as well as 1 and 3 months later	Number varies for each outcome for the 3 time points. Knowledge: I: 191, 172, 164 C: 168, 146, 139	Knowledge about cancer	Mean score (SD). Before I: 59% (20) C: 60% (20); 1 month I: 65% (20) C: 63% (20); 3 months I: 66% (20) C: 63% (20). Significantly greater increase in knowledge over time in intervention group (P = 0.035)
			CDCI: I: 191, 172, 163 C: 167, 147, 140 MAS: I: 190, 167, 160 C: 166, 146, 138	Self‐reported adherence to medications: 1. CDCI (Chronic Disease Compliance Instrument) 2. MAS (Medication Adherence Scale)	1. CDCI mean score (SD), range of 18‐90 with higher scores representing greater adherence: Before I: 79.2 (7.9), C: 77.4 (7.5); 1 month I: 79 (8.3), C: 78.4 (7.7); 3 months I: 81 (8.7), C: 78.4 (7.5). 2. MAS mean score (SD), range from 0‐4 with higher scores indicating greater adherence: Before I: 2.9 (1.1), C: 2.9 (1.1); 1 month I: 3.0 (1.1), C: 3.1 (1.0); 3 months I: 2.9 (1.1), C: 3.0 (1.1).
			6‐MP metabolite assays: I: 28, 24, 23 C: 26, 22, 23 MEMS (only measured at 3 months): I: 107 C: 93	Objective measures of adherence to medications: 1. 6 ‐MP adherence using metabolite assays: 6‐TG and 6‐MMP 2. TMP/SMX adherence using Medication Event Monitoring System (MEMS)	1. 6‐MP mean metabolite level (SD). 6‐TG: Before I: 250.7 (245.3) C: 284.3 (206.4); 1 month I: 283 (230.1), C: 302.1 (214); 3 months I: 286.5 (307.4), C: 236.8 (148.2). 6‐MMP: Before I: 10484.6 (9920.6) C: 9218 (11004.2); 1 month I: 11168.9 (12107.5), C: 10349.9 (11667.1); 3 months I: 8499.1 (7600.3), C: 8087.0 (9123.6). 2. MEMS mean (SD) % prescribed doses taken: At 3 months. I: 62.3% (62.9). C: 52.5% (37.6) Medication adherence did not differ significantly between groups when measured using self‐report: CDCI (P = 0.78), MAS (P = 0.503) but did differ significantly on objective measures: 6‐MP metabolites (P = 0.041), MEMS (P = 0.012).
				Clinic visit attendance	Mean: 98+/‐ 1% of scheduled visits were attended across both groups with no significant difference between the groups P = 0.65
			I: 191, 172, 164 C: 168, 148, 139	Self‐efficacy	Mean score (SD). Range 27‐189 with higher scores representing greater self‐efficacy. Before I: 155.9 (22.3), C: 156.6 (21.3); 1 month I: 158 (24.3), C: 157.9 ( 22.3); 3 months I: 164.1 (23.4), C: 158.8 (23.5). Significantly greater self‐efficacy in intervention group (P = 0.011).
			PQL: I: 154, 143, 119 C: 134, 119, 102 FACT‐G: I: 32, 25, 23 C: 31, 29, 25	Quality of life (QOL): 1. PQL (Paediatric Quality of Life) 2. FACT‐G (Functional Assessment of Cancer Therapy)	1. PQL: Mean score (SD). Range 0‐100 with higher score representing better QOL. Before I: 64.2 (15.4) C: 62.5 (17,4); 1 month 65.5 (15.1) C: 63.5 (17.6); 3 months I: 69.1 (15.1) C: 66.3 (17.3). 2. FACT‐G: Mean score (SD). Range 0‐108 with higher score representing better QOL. Before I: 11.3 (2.6), C: 10.7 (2.7); 1 month I: 11 (3.2) C: 11.1 (2.1); 3 months I: 12.2 (2.9), C: 11.3 (2.8). No significant difference between groups for QOL: PQL (P = 0.112), FACT‐G (P = 0.15).
			I: 191, 170, 162 C: 168, 146, 139	Perceived stress	Mean score (SD). Range 10‐50 with higher score representing more stress. Before I: 34.4 (7.4), C: 33.1 (6.6); 1 month I: 36.5 (6.6), C: 35.2 (6.8); 3 months I: 38.1 (6.9), C: 35.7 (6.2). No significant difference between groups (P = 0.931)
			I: 190, 171, 164 C: 168, 147, 139	Health Locus of Control Subscales: 1. Self/Internal 2. Chance 3. Powerful others 4. Doctors 5. Other people	Mean score (SD). Range 3‐36 for each sub‐scale with higher scores representing higher locus of control. Before I: 18.9 (6.1), C: 18.6 (5.3); 1 month I: 18 (5.9), C: 18.2 (5.8); 3 months I: 17.6 (6.6), C: 17.7 (6.2). Before I: 20.3 (6.6), C: 20.7 (7.3); 1 month I: 19.1 (6.1), C: 20 (6.6); 3 months I: 18.7 (6.8), C: 19.4 (6.9). Before I: 26.4 (4.7), C: 26.5 (4.6); 1 month I: 26.1 (5.1), C: 26.4 (4.6); 3 months I: 25.7 (5.3). C 26.2 (4.8). Before I: 15.2 (2.5) C:15.4 (2.6); 1 month I: 15 (2.8), C: 15.1 (2.8); 3 months I: 14.7 (2.9), C: 15 (2.6) Before I: 11.1 (3.4), C: 11.1 (3.5); 1 month I: 11.2 (3.4), C: 11.4 (3.2); 3 months I: 11 (3.7), C: 11.2 (3.3). No significant difference between groups on overall health locus of control score (P = 0.608).
Kinnane 2008	Multimedia and co‐intervention (I) versus co‐intervention alone (C)	At time of 2nd chemotherapy cycle (˜3 to 4 weeks post‐intervention)	I: 31 C: 29	Knowledge ‐ recall of content in the pre‐chemotherapy education. (results reported for each question).	No statistically‐significant difference in I and C group results for any question. The authors reported a trend towards higher recall in the video group for 3 questions: what mouth problems should be reported straight away (87% vs 78%, P = 0.45); symptoms of low red cell count (80.6% vs 66.7%, P = 0.29); prevention of constipation (74.2% vs 51.7%, P = 0.07).
Kinnane 2008			I: 31 C: 29	Use of health services	Number of patient phone calls to the chemotherapy centre I: 25, C: 27; Number of phone calls relating to education content I: 20/25, C: 15/27.
Knoerl 1999	Multimedia (I) vs usual care (C)	Preoperatively and 4, 8 and 24 hours postoperatively	I: 38 C: 38	Knowledge about PCA (measured pre and 4 hours post‐op)	Mean score (SD). Pre I: 65.4% (22.4), C: 56.6% (25.9), P = 0.13; Post I: 95.6% (8.4), C: 75.8% (17.6), P = 0.00.
				Attitude to pain medications (measured pre and 4 hours post‐op)	Mean score (SD) with higher score indicating more positive attitude. Pre I: 72% (28.5), C: 72% (28.2), P = 1.00; Post I: 95.6% (9.2), C: 72.4% (23.3), P = 0.00.
				Satisfaction with pain management	Mean (SD), range 1‐6 with high score representing low satisfaction: 4 hours post I: 1.4 (0.68), C: 1.8 (0.93), P = 0.03; 8 hours post I: 1.2 (0.37) C: 1.5 (0.60), P = 0.01; 24 hours post I: 1.2 (0.41), C: 1.5 (0.60), P = 0.10
				Pain	Mean pain rating (SD) from 0‐10 with 0 = no pain and 10 = worst possible pain. 4 hours post I: 4.0 (2.5), C: 5.3(3), P = 0.06; 8 hours post I: 3.2 (2.3), C: 3.9 (2.4), P = 0.27; 24 hours post I: 3.0 (2.1), C: 3.5 (2.1), P = 0.42.
				Incidence of medication side effects	Percent who experienced side effect: Nausea I: 42.1%, C: 34.2%, P = 0.48; vomiting I: 18.4%, C: 10.5%, P = 0.33; pruritis I: 28.9%, C: 34.2%, P = 0.63; hypotension I and C: 5.3%, P =1.0; sedation I: 21.1%, C: 28.9%, P = 0.43; urinary retention I: 10.5%, C: 13.2%, P = 0.73.
Lirsac 1991	Multimedia (I) vs verbal (C)	Before the intervention and after 15 days.	I: 14, C: 14	Inhaler technique	Mean change in inhaler technique score: I: ‐2.65, C: ‐1.65 (P < 0.05). Errors in inhaler technique following education (number of patients): I: 0 errors = 8, 1 error = 6. C: 0 errors = 6, 1 error = 4, 2 errors = 4. Mean inhaler technique score following education (SD ‐ estimated from figure) I:0.45 (0.5), C:0.85 (0.9). Baseline mean inhalation score was significantly better in the control group I: 3.1 (0.7), C: 2.5 (0.5), P < 0.05.
Lirsac 1991	Multimedia (I) vs verbal (C)	Before the intervention and after 15 days.	I: 14, C: 14	Bronchial obstruction	FEV: Baseline I: Pre MDI 1.89 (0.61), Post MDI 2.35 (0.74), C: Pre MDI 2.01 (0.7), 2.53 (0.84). 15 days after education I: Pre MDI 2.38 (0.84), Post MDI 2.66 (0.74), C: Pre MDI 2.09 (0.63), Post MDI 2.66 (0.74). Theoretical maximum FEV I: 2.73 (0.72), C: 3.14 (0.6)
Mazor 2007	Multimedia (I) vs usual care (C)	Before the intervention and 3 weeks later	Number varies for each outcome: I: 220, C: 87	Knowledge about warfarin	Mean score (SD) Before I: 57.5% (16), C: 54% (18) After I: 68.95% (16.07), C: 57% (17).
			I: 220, C: 86	Self‐reported non‐adherence to warfarin dosing	Percent reporting non‐adherence. Before I: 6.8%, C: 5.8%, After I: 3.6%, C: 3.5%
			I: 213, C: 85	Self‐reported intention to adhere to laboratory testing	Mean score (SD) range 1‐5 with higher score indicating stronger intent to adhere. Before I: 3.7 (1.1), C: 3.7 (1.0); After I: 3.93 (0.99), C: 3.81 (0.96).
			I: 175, C: 57	Non‐attendance at laboratory appointments	Number (%) not attending. Before I: 35/175 (20%), C: 10/57 (17.5%); After I: 38/175 (22%), C: 19/57 (33%).
			Subscale 1: I: 221, C: 89 Subscale 2: I: 219, C: 89 Subscale 3: I: 215, C: 85 Subscale 4: I: 221, C: 89	Beliefs about warfarin sub‐scales: 1. Belief warfarin is beneficial 2. Belief warfarin is worrisome 3. Belief warfarin regimen is confusing or difficult 4. Belief that laboratory testing is important	Mean scores (SD) with range 1‐5 with higher scores representing greater belief in benefit, less worry, confusion or difficulty and stronger belief in importance of testing. 1. Belief warfarin is beneficial: Before I: 3.45 (0.78), C: 3.47 (0.75); After I: 3.57 (0.8), C: 3.44 (0.74). 2. Belief warfarin is worrisome: Before I: 3.11 (0.94), C: 3.21 (0.89); After I: I:2.97 (0.98), C: 3.31 (0.85). 3. Belief warfarin regimen is confusing or difficult: Before I: 4.28 (0.55), C: 4.21 (0.63); After I: 4.27 (0.58), C: 4.19 (0.65) 4. Belief that laboratory testing is important: Before I: 4.16 (0.74), C: 4.06 (0.71); After I: 4.26 (0.68) C: 4.03 (0.7).
McElnay 1989	Multimedia plus written education (I) vs instruction by a health professional plus written education (V) vs written education (C)	Immediately after the intervention and 2 weeks later	Immediately after the intervention N = 50 in all three groups Two weeks later: I: 43 V: 40 C: 44	Skill acquisition (inhaler technique)	Immediately after the intervention (mean score out of 80 (SD)) I: 60 (14.85), V: 64.2 (6.36), C: 49.5 (13.44); P values: I vs V: P > 0.05, I vs C: P < 0.001; V vs C: P < 0.001 2 weeks later I: 50 (26.2), V: 59.5 (12.65), C: 47.3 (17.25); P values: I vs V: P > 0.05, I vs C: P < 0.05; V vs C: P < 0.001
Navarre 2007	Multimedia (I) vs usual care (C)	Immediately after the intervention	I: 18 C: 16	Knowledge of inhaler technique	Mean score (SD) I: 80.9% (17), C 67.4% (11.8), P = 0.01
Navarre 2007	Multimedia (I) vs usual care (C)	Immediately after the intervention	I: 18 C: 16	Skill acquisition (inhaler technique)	Mean score out of 100 (SD) I: 88.3 (12.3), C: 67.4 (19.2), P = 0.001
Neafsey 2001	Multimedia (I) vs usual care (C)	Immediately after the intervention	I: 30 C: 30	Knowledge about interaction of prescribed medications with OTC antacids and alcohol.	Mean score (SD) I: 71.7% (19.1), C: 36.2% (16.5), (P ≤ 0.001).
Neafsey 2001	Multimedia (I) vs usual care (C)	Immediately after the intervention	I: 30 C: 30	Self‐efficacy	Mean score (SD) scored from 1‐5 with higher scores representing greater self‐efficacy I: 3.14 (0.9), C: 1.76 (0.99), (P ≤ 0.001).
Neafsey 2002	Multimedia plus written information (I) vs written information (C)	Immediately after the intervention, 2 and 4 weeks later (except for risk of adverse medication behaviour which was assessed pre‐intervention, 2 and 4 weeks later)	I: 30 C: 30	Knowledge about interaction of prescription medications with OTC preparations and alcohol.	Mean score (SD) Post intervention I: 72.8% (16.8), C: 53.7% (18.7); At 2 weeks I: 77.6% (20.5), C: 55.2% (20); At 4 weeks I: 79.9% (21), C: 56.7% (20), P < 0.05 at all time points.
				Self‐efficacy	Mean score and SD (range 1‐5) with higher scores representing higher self‐efficacy. Post intervention I: 3.7 (0.8), C: 3.1 (0.95); At 2 weeks I:3.7 (0.8), C:2.8 (0.9), At 4 weeks I:3.9 (0.7), C:3.0 (0.8), P < 0.05 at all time points.
				Risk of adverse medication behaviour	Mean score and SD (range 0‐40) with higher score representing riskier behaviour Pre‐intervention I: 21 (11), C: 22 (14); At 2 weeks I: 18 (10.5), C: 22 (13); At 4 weeks I: 16 (10), C: 21 (10)
Olver 2009	Multimedia (I) vs written information (C)	3‐4 week after the intervention	I: 47 C: 54	Recall of information about chemotherapy	Number who answered each question correctly. Number of drugs I: 26/47 C: 25/54, P = 0.43. Treatment length I: 30/47, C:27/54, P = 0.23. Treatment goal I: 25/47, C: 31/54, P = 0.69.
				Satisfaction with information	Across both groups 66.4% found the information very or somewhat helpful and 53.5% felt that is was the right amount. Authors stated that there was no significant difference between groups on these variables.
				Usability of the information	Across both groups 45.5% read all of the information and 27.7% felt they understood all of the information. Authors stated that there was no significant difference between the groups in these variables.
				Anxiety level	Across both groups 30% felt the information dispelled their anxiety, 33% felt no different and 11% became more anxious. Authors stated that there was no significant difference between the groups.
Osguthorpe 1983	Multimedia plus written information (I) vs written information alone (W) Multimedia alone (I) vs usual care (C)	One week before and after the intervention	N = 202. The number in each arm was not reported	Knowledge about psychiatric medications.	Mean change scores from baseline for individual questions in each cluster were reported. The authors stated that there were no differences between groups based on total change scores but these were not reported.
Powell 1995	Multimedia (I) vs usual care (C)	Time of enrolment to completion of the study or termination from the HMO plan (maximum 9 months)	I: 1993 C: 2253	Compliance using the Medication Possession Ratio (MPR): the number of days' supply of medication obtained by patient divided by the number of days the patient was observed.	Mean MPR (SD) I: 0.70 (0.23), C: 0.70 (0.28). Number with MPR ≥ 0.8 I: 917 (46%), C: 998 (44%)
Savage 2003	Multimedia (I) vs written education (C)	Immediately before and after the intervention	I: 52 C: 43	Skill acquisition (inhaler technique)	Change in global inhaler technique rating: number worse than baseline I: 2/52, C: 4/43; same as baseline I: 27/52, C: 31/43; better than baseline I: 23/52, C: 8/43. Number who checks mouthpiece I: 10/52, C: 3/43; shakes inhaler I: 41/52, C: 32/43; coordination I: 28/52, C: 12/43; breathes in I: 27/52, C: 18/43.
Schnellinger 2010	Multimedia (I) vs written (P) vs control (C)	Immediately before (pre) and after (post) the intervention and after 4 weeks	Post: I: 83 P: 79 C: 84 At 4 weeks: I: 65 P: 63 C: 61	Knowledge about appropriate antibiotic use	Median score out of 10 (range): Pre I: 9 (2‐10), P: 8 (1‐10), C: 8 (1‐10), Post I: 10 (2‐10), P: 10 (1‐10), C: 8 (0‐10), 4 weeks I: 10 (2‐10), P: 9 (2‐10), C: 8 (1‐10). Numbers who had perfect scores at baseline I: 20 (31%), P: 13 (21%), C: 11 (18%). Number who improved following intervention (based on pre and post scores): I: 38 (58%), P: 45 (71%), C: 17 (28%). With percentages calculated after excluding participants with perfect scores at baseline: I: 85%, P: 90%, C: 34%.
Schnellinger 2010	Multimedia (I) vs written (P) vs control (C)			Evaluation survey	Percent answering yes: Q1. Found the study useful/interesting I: 93, P: 95, C: 80. Q2. Learnt something new about antibiotics I: 72, P: 84, C: 30. Q3. Paediatrician talked about proper use of antibiotics I: 59, P: 33, C: 70. Q4. Paediatrician talked about improper antibiotic use I: 61, P: 58, C: 66. Q5. Paediatrician offered antibiotics more often than needed I: 11, P: 11, C: 16. Q6. Would you ask Paediatrician for antibiotics for conditions mentioned in study (where antibiotics are not appropriate) I: 15, P: 35, C: 45. Q7. Do you think there is an antibiotic for every infection I: 12, P: 10, C: 12. Q8. Did you know about antibiotic resistance prior to the study I: 76, P: 63, C: 63. Q9. If you knew that doctor would not give an antibiotic would you still go to the doctor I: 58, P: 56, C: 51.
Schwarz 2008a	Multimedia education (I) vs control multimedia (C)	Before and 6 months after the intervention	I: 127 C: 138	Knowledge about emergency contraception (EC)	Number who learned: one or more things about EC I: 97/127 (76%), C: 86/138 (62%), P = 0.04. Mean scores baseline I:59%, C:62%, P = 0.12. Mean scores 6 months I:59%, C:58%, P = 0.88. EC is available in California I: 24%, C: 18%, P = 0.36; EC is safe I: 26%, C: 12%, P < 0.001; EC is effective I: 22%, C: 14%, P = 0.29; EC will not adversely affect future fertility I: 37%, 20%, P = 0.005; EC will not cause birth defects or miscarriage I: 34%, C: 14%, P < 0.001; EC can be used 3‐5 days after condom breaks I: 28%, C: 19%, P = 0.005; EC does not protect from STD I: 11%, C: 6%, P = 0.31; A period is expected within 3 weeks of taking EC I: 20%, C: 14%, P = 0.33.
				Attitude to EC	Number (%) who had personal objection to EC pre‐intervention: I: 19/219 (9%) C: 13/227 (6%). Number (%) who developed a more positive attitude toward EC after the intervention I:10/219 (8%), C: 6/227 (4%), P = 0.06.
				Self‐reported use of EC during study period	Number who used EC I: 6%, C: 3%, P = 0.09 Number who had supply of EC in the home I: 34%, C: 7%, P < 0.001.
				Conception during study period	Number who conceived I: 2.7%, C: 5.7%, P = 0.12.
Self 1983	Multimedia (I) vs education by a health professional (V) vs written education (C)	All groups assessed immediately after the intervention. I and V groups also assessed between 1‐16 weeks later.	Immediately after: I: 10 V: 9 C: 10 1‐16 weeks later: I: 8 V: 7	Skill acquisition (inhaler technique)	Mean inhaler technique score out of 20. Immediately after the intervention (SD) I: 16.9 (5.0), V: 16.8 (4.5), C: 10.7 (4.5). 1‐16 weeks later I: 14.3 (5.8), V: 17.4 (2).
Solomon 1988	Multimedia plus verbal instruction from doctor +/‐ special pill packaging (I) vs verbal instruction from doctor +/‐ special pill packaging (C)	2 or 6 days after starting the medication	N = 321, 38 to 42 participants in each of the 8 groups and approximately half exposed to the multimedia intervention.	Knowledge about tetracycline for treatment of STDs	Mean score out of 15. I: 14.4, C: 10.7. ANOVA F‐ratio = 442.7, P < 0.001.
				Non‐compliance with medication	Mean score (range 0‐160 with higher scores indicating worse compliance) I: 8.3, C: 40.45. Authors reported that the multimedia group had better compliance based on ANOVA result (F‐ratio = 114.2, P < 0.001).
				Premature resumption of sexual activity	Median percentage who resumed sexual activity prematurely I: 3%, C: 22%, ANOVA F‐ratio = 30.2, P < 0.001.
				Satisfaction with care	Authors reported that results for these variables were significantly improved in patients who had received multimedia education and/or special pill packaging compared to patients who had received neither: F (1312) = 5.1 P < 0.025.
				Perception of disease severity	F(1312) = 5.1 P < 0.026
				Confidence in medication	F(1312) = 6.1 P < 0.015
Stone 1989	Multimedia (I) vs education by a health professional (C)	Immediately before and after the intervention	I: 9 C: 13	Knowledge about warfarin	Mean score out of 18 (SD) Before I:12.6 (2.6), C:12.8 (1.4); After I:15.6 (1.4), C:16 (1.4), P = 0.60.
				Satisfaction with education	Mean score out of 25 I: 23.2, C: 24.8 Authors state that there was no significant difference.
				Use of health services	Time required for teaching (mean time in minutes) I: 17.6 (duration of video), C:26 (5.7) (mean (SD) duration of nurse lecture). Time required for questions after education (mean time in minutes) I: 7.5 (7.2) C: 6.3 (5.3)
Trent 2010	Multimedia plus usual care (I) vs usual care alone (C)	After two‐week treatment period	I: 36 C: 41	Adherence with medications	Number that completed the medication course: I: 23 (64%), C: 27 (66%).
				Attendance at 72 hour clinical visit	Number who attended: I: 11 (31%), C: 6 (15%).
				Abstinence from intercourse	Number who abstained: I: 25 (69%), C: 31 (76%)
				Partner notification	Number who notified partner: I: 30 (83%). C: 35 (85%)
				Partner treatment	Number who reported that partner had been treated: I: 24 (67%), C: 20 (49%)
				Complications	Number who reported complications: I: 13 (36%), C: 13 (32%).
Van Der Palen 1997	Multimedia (I) vs education by a health professional (V) vs usual care (C)	At first scheduled clinic visit up to 9 months later	I: 38 V: 77 C: 33	Skill acquisition (inhaler technique)	Mean inhaler checklist scores I: 91%, V: 91%, C: 74%; Essential checklist items (mean score) I: 92%; V: 95% C: 76%; Percent of patients with a 100% score I: 76%, V: 86%, C: 49%.
Voris 1982	Multimedia (I) vs usual care (C)	Before the intervention, and both 1‐5 days and 4 weeks after the intervention	After 1‐5 days: I: 6 C: 5 After 4 weeks: I: 4 C: 4	Knowledge about tricyclic antidepressants.	After 1‐5 days (mean score out of 20 (and range)) I: 19 (18‐20), C: 13.6 (8‐17); After 4 weeks I: 17.3 (16‐19), C: 12.8 (7‐18).

Table 2. Study outcome data

Table 3. Summary of key participant and intervention characteristics across included studies

Characteristics of study participants
Characteristic		Number of studies	Study titles
Country in which study is set	USA	16	Acosta 2009; Deitz 2011; Knoerl 1999; Mazor 2007; Navarre 2007; Neafsey 2001; Neafsey 2002; Osguthorpe 1983; Powell 1995; Schnellinger 2010; Schwarz 2008a; Self 1983; Solomon 1988; Stone 1989; Trent 2010; Voris 1982
	United Kingdom	3	Goodyer 2006; McElnay 1989; Savage 2003
	Australia	2	Kinnane 2008; Olver 2009
	Netherlands	1	Van Der Palen 1997
	France	1	Lirsac 199
	Multi‐centre study in the USA, Canada and Australia	1	Kato 2008
Setting from which participants were recruited	Community or hospital‐based outpatient clinics, treatment centres and inpatient wards	15	Kato 2008; Kinnane 2008; Knoerl 1999 Lirsac 1991; Mazor 2007; Navarre 2007; Olver 2009; Osguthorpe 1983; Savage 2003; Self 1983; Solomon 1988; Stone 1989; Trent 2010; Van Der Palen 1997; Voris 1982
	Emergency departments or urgent care clinics	3	Acosta 2009; Schnellinger 2010; Schwarz 2008a
	Local seniors centres	2	Neafsey 2001; Neafsey 2002
	Turkish social clubs	1	Goodyer 2006
	HMO members who had pharmacy claims for particular medications	1	Powell 1995
	Volunteers from staff at participating hospitals	2	Deitz 2011; McElnay 1989
Gender	Only women	3	Deitz 2011; Schwarz 2008a; Trent 2010
Gender	Only men	1	Osguthorpe 1983
Age	Adults only (17 years or older). Three studies dealt with specific age groups; Neafsey 2001 and Neafsey 2002 recruiting seniors aged 60 years or older and Schwarz 2008a recruiting women of childbearing age (aged 18 to 45 years)	19	Acosta 2009; Deitz 2011; Goodyer 2006; Kinnane 2008; Knoerl 1999; Mazor 2007; McElnay 1989; Navarre 2007; Neafsey 2001; Neafsey 2002; Olver 2009; Osguthorpe 1983; Powell 1995; Schnellinger 2010; Schwarz 2008a; Self 1983; Stone 1989; Van Der Palen 1997; Voris 1982
Age	Also recruited children. Kato 2008 recruited children, adolescents and young adults aged 13 to 29 years, Trent 2010 recruited adolescents aged 15 to 21 years, Savage 2003 included patients aged 12 to 87 years old, Lirsac 1991 recruited participants aged 10 to 71 years old and Solomon 1988 included participants aged 14 to 59 years old (mean age 23).	5	Kato 2008; Lirsac 1991; Savage 2003; Solomon 1988; Trent 2010
Language in which education was provided	English	19	Deitz 2011; Kinnane 2008; Knoerl 1999; Mazor 2007; McElnay 1989; Navarre 2007; Neafsey 2001; Neafsey 2002; Olver 2009; Osguthorpe 1983; Powell 1995; Savage 2003; Schnellinger 2010; Schwarz 2008a; Self 1983; Solomon 1988; Stone 1989; Trent 2010; Voris 1982
	Dutch	1	Van Der Palen 1997
	Turkish	1	Goodyer 2006
	French	1	Lirsac 1991
	More than one language (Kato 2008 using English, French or Spanish and Acosta 2009 using both English and Spanish)	2	Acosta 2009; Kato 2008
Educational level	Mean number of years of education completed. Combined results from the 4 studies showed that the 243 participants completed a mean of 13.5 years of education.	4	Knoerl 1999; Neafsey 2001; Neafsey 2002; Stone 1989
	Highest level of education completed. Of the combined 2616 participants from the 11 studies, 49% had completed some primary or secondary school while 48% had attended tertiary level education.	11	Acosta 2009; Deitz 2011; Kato 2008; Kinnane 2008; Mazor 2007; Navarre 2007; Olver 2009; Osguthorpe 1983; Schnellinger 2010; Schwarz 2008a; Solomon 1988
	Low versus high level. One study reported that 82% of its 148 participants had a low educational level and 18% had a high level but did not provide definitions for these levels.	1	Van Der Palen 1997
	Participants' level of educational attainment was not reported.	8	Goodyer 2006; Lirsac 1991; McElnay 1989; Powell 1995; Savage 2003; Self 1983; Trent 2010; Voris 1982
Literacy	Comprehension score of at least grade six on the Rapid Estimate of Adult Literacy Measure (REALM)	2	Neafsey 2001; Neafsey 2002
	One study reported that over 80% of the participants were literate in Turkish when assessed using a language proficiency test devised by their language department.	1	Goodyer 2006
	No information reported about literacy	21	All other studies
Primary diagnosis and treatment; topic of the educational program	Respiratory illnesses treated with metered dose inhalers (MDIs); MDI technique	7	Acosta 2009; Goodyer 2006; Lirsac 1991; Navarre 2007; Savage 2003; Self 1983; Van Der Palen 1997
	Malignancies treated with chemotherapy; chemotherapy and management of its side effects	3	Kato 2008; Kinnane 2008; Olver 2009
	Conditions requiring anticoagulation with warfarin; warfarin	2	Mazor 2007; Stone 1989
	Psychiatric illnesses treated with specific medications; specific psychiatric medications	2	Osguthorpe 1983; Voris 1982
	Elderly patients taking particular over‐the‐counter medications e.g. antacids and pain relievers; interaction between prescription and over‐the counter medications	2	Neafsey 2001; Neafsey 2002
	Sexually transmitted diseases (STD) or pelvic inflammatory disease (PID) treated with antibiotics; treatment of STD or PID with antibiotics	2	Solomon 1988; Trent 2010
	Hypertension, hypercholesterolaemia or menopause treated with specific medications; specific medications for these conditions	1	Powell 1995
	Undergoing a surgical procedure requiring post‐operative patient‐controlled analgesia (PCA); PCA	1	Knoerl 1999
	Did not require participants to have a particular medical condition or to have taken a particular medication: female hospital employees ‐ education about medications with abuse potential including strategies for avoiding drug use and dependence; volunteers with no experience of MDI use ‐ education about MDI technique; parents of children presenting for acute care ‐ education about proper antibiotic use; women of child‐bearing age attending emergency department ‐ education about emergency contraception.	4	Deitz 2011; McElnay 1989; Schnellinger 2010; Schwarz 2008a
Acuity of the primary diagnosis	Acute	3	Knoerl 1999; Solomon 1988; Trent 2010
	Chronic	16	Acosta 2009; Goodyer 2006; Kato 2008; Kinnane 2008; Lirsac 1991; Mazor 2007; Navarre 2007; Neafsey 2002; Olver 2009; Osguthorpe 1983; Powell 1995; Savage 2003; Self 1983; Stone 1989; Van Der Palen 1997; Voris 1982
	Unclear	1	Neafsey 2001
Characteristics of interventions
Format	Video: 10 studies used videotapes, two studies DVDs and two studies did not report the technology used to deliver the video.	14	Acosta 2009; Kinnane 2008; Knoerl 1999; Lirsac 1991; Mazor 2007; McElnay 1989; Osguthorpe 1983; Powell 1995; Schnellinger 2010; Self 1983; Solomon 1988; Stone 1989; Trent 2010; Van Der Palen 1997
	Computer‐based program: four studies used programs with touch‐screen technology and the program used in one study was a computer game.	9	Deitz 2011; Goodyer 2006; Kato 2008; Navarre 2007; Neafsey 2001; Neafsey 2002; Olver 2009; Savage 2003; Schwarz 2008a
	Slide audiovisual presentation	1	Voris 1982
Source of the multimedia program	Developed by the study authors	19	Deitz 2011; Goodyer 2006; Kato 2008; Kinnane 2008; Mazor 2007; McElnay 1989; Navarre 2007; Neafsey 2001; Neafsey 2002; Olver 2009; Osguthorpe 1983; Savage 2003; Schnellinger 2010; Schwarz 2008a; Self 1983; Solomon 1988; Stone 1989; Trent 2010; Voris 1982
	Developed by other organisations ‐ pharmaceutical companies and a national medical media company	2	Powell 1995; Van Der Palen 1997
	Not reported	3	Acosta 2009; Knoerl 1999; Lirsac 1991
Consumer involvement in development of the program	Studies that reported consumer involvement in the development of the multimedia program	6	Kato 2008; Mazor 2007; McElnay 1989; Neafsey 2001; Neafsey 2002; Trent 2010
Number of times the multimedia program was viewed and success at reaching target audience	All participants viewed the program on at least one occasion	20	Acosta 2009; Goodyer 2006; Kinnane 2008; Knoerl 1999; Lirsac 1991; McElnay 1989; Navarre 2007; Neafsey 2001; Neafsey 2002; Olver 2009; Osguthorpe 1983; Savage 2003; Schnellinger 2010; Schwarz 2008a; Self 1983; Solomon 1988; Stone 1989; Trent 2010; Van Der Palen 1997; Voris 1982
	Known number of participants who did not view the program on at least one occasion ‐ 4% (Deitz 2011), 13% (Kato 2008)	2	Deitz 2011; Kato 2008
	Number who did not view the program not known ‐ Powell 1995 sent a questionnaire to a subset of 205 of the 1993 participants of which 97 (47%) were returned. Of these, 13% reported that they had not viewed the video.	2	Mazor 2007; Powell 1995
	Rates of repeat viewing of the program reported ‐ 36.2% and 88% viewed program more than once in Olver 2009, Deitz 2011 respectively, 33% viewed program for the requested duration of one hour/week in Kato 2008 and the program was viewed a median of three times (range 1 to 50) in Van Der Palen 1997	4	Deitz 2011; Kato 2008; Olver 2009; Van Der Palen 1997
	Rates of repeat viewing not measured or reported	2	Mazor 2007; Powell 1995
Assistance from staff	Studies reporting that research staff or health professionals provided assistance in viewing or using the multimedia program	4	Goodyer 2006; Navarre 2007; Olver 2009; Savage 2003
Degree of interactivity of the computer based programs (none of the programs using other formats contained any interactive features)	Limited	6	Goodyer 2006; Neafsey 2001; Neafsey 2002; Olver 2009; Savage 2003; Schwarz 2008a
	Sections with both limited and full interactivity	1	Deitz 2011
	Full	1	Kato 2008
	Not reported	1	Navarre 2007
Tailoring	Program tailored to an individual users' characteristics	2	Deitz 2011; Olver 2009

Table 3. Summary of key participant and intervention characteristics across included studies

Table 4. Description and evaluation of interventions

Study

Intervention

Comparators

Acosta 2009

Source of information about intervention: Information provided by the author in the published thesis.

Description of intervention: Video demonstrating steps for correct MDI use.

Name of program: Not reported

Country of origin: USA

Language: English and Spanish

Year program used in the study was produced: Not reported

Stated expertise of content developers: Not reported

Stated expertise of program developers: Not reported

Process of development and testing: Not reported.

Availability: Not reported

Purpose: To demonstrate correct inhaler technique to patients with asthma

Content: Video containing pictures describing the different steps in properly using an MDI.

Relationship between developer and user: Health professionals to patients.

Target audience: Asthma patients

Format: Video

Hardware required: Television and video player

Media: Video and audio

Delivery: Viewed on site in the emergency department

Length of program: 10 minutes

Number of times program was used: Patients only viewed the video on one occasion.

Time point of delivery: Participants had existing asthma therefore it is assumed that they were using MDIs prior to the study. 58% had previously received training about correct use of an MDI.

Success at reaching target audience: The video was administered on site therefore all participants in the intervention arm viewed the program.

Assistance: Not reported

Interactivity: No

Tailoring: No

Source of information about comparators: Information provided by the author in the published thesis

Description of comparator: Video about asthma.

Name of program: Not reported

Country of origin: USA

Language: English and Spanish

Year program used in the study was produced: Not reported

Stated expertise of content developers: Not reported

Stated expertise of program developers: Not reported

Process of development and testing: Not reported.

Availability: Not reported

Purpose: To provide general information about asthma and its triggers.

Content: Video explains issues faced by patients with asthma and asthma triggers but does not contain any MDI related instructions.

Relationship between developer and user: Health professionals to patients.

Target audience: Asthma patients

Format: Video

Hardware required: Television and video player

Media: Video and audio

Delivery: Viewed on site in the emergency department

Length of program: 10 minutes

Number of times program was used: Patients only viewed the video on one occasion.

Time point of delivery:

Success at reaching target audience: The video was administered on site therefore all participants in the control arm viewed the program.

Assistance: Not reported

Interactivity: No

Tailoring: No

Evaluation of intervention:

Inadequate information was provided on which to base an assessment

Evaluation of comparator:

Inadequate information was provided on which to base an assessment

Deitz 2011

Source of information about intervention: Copy of the program as well as information provided by the author in the published study.

Description of intervention: Multimedia program designed to prevent the misuse of psychoactive prescription drugs.

Name of program: SmartRx: Your Prescription for Good Health

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported

Stated expertise of program developers: The authors have experience in the development of Internet and DVD‐based health programs.

Availability: Access to the program was provided on request by the study authors.

Purpose: To prevent the misuse of psychoactive prescription medications.

Relationship between developer and user: Health professionals to patients.

Target audience: Women who are currently using or anticipate the use of medications with abuse potential.

Format: Web‐based multimedia program

Hardware required: Computer with Internet access.

Media: Text, graphics, animations, video and audio

Delivery: Participants accessed the program over the Internet.

Success at reaching target audience: Seven participants in the multimedia group did not use the program.

Assistance: None

Source of information about comparators: Information provided by the author in the published study

Description of comparator: Waiting list controls who did not receive any education.

Headings: Each section has a heading and a series of subheadings. Section headings are also listed in a panel to the left of the main screen and can be used to navigate through the program.

Technicality of language: Medical terminology was used but it was accompanied by a definition or explanation.

Factual content: The program did not state the source of the information or the date it was produced.

Evaluation of comparator:

Not applicable

Goodyer 2006

Source of information about intervention: Information provided by the authors in the published study and a copy of the voice‐over script for the English version of the program.

Description of intervention: Multimedia program demonstrating metered dose inhaler technique. This study used the Turkish version of the program used in Savage 2003.

Name of program: Multimedia Touch Screen System (MTS)

Country of origin: England

Language: Turkish (however the program is available in other languages including English)

Year program used in the study was produced: Not reported

Stated expertise of content developers: Pharmacy Practice Group King's College London.

Stated expertise of program developers: Not reported

Process of development and testing: Not reported other than to state that the content was based on that of the "how to use your inhaler" section of the Ventolin PIL.

Availability: No longer available.

Purpose: To demonstrate correct inhaler technique to Turkish patients with asthma

Relationship between developer and user: Health professionals to patients.

Target audience: Turkish asthma patients with poor English skills

Format: Computer‐based multimedia touch‐screen system

Hardware required: Computer with touch‐screen

Media: Video and audio

Delivery: Viewed on a computer in the patient's home

Length of program: Not reported

Number of times program was used: Patients only used the program on one occasion but were allowed to use it for as long as they wished

Time point of delivery: Patients were longstanding inhaler users (mean years (SD) = 8.8 (8.9)

Assistance: The authors state that patients required "little instruction on use of the system" but do not describe this further

Interactivity: Limited. Users could interact with the program using a touch‐screen that allowed them to navigate through the program.

Tailoring: No

Description of comparators:

1. Patient information leaflet (PIL)

2. Verbal support

Evaluation of intervention:

Generic structure: The program focused on the information contained in the "How to use your inhaler" section of the PIL. It therefore only contained the "Dosage instructions" move.

Tenor: Unable to assess

Metadiscourse: The purpose of the program was clearly stated at the beginning.

Headings: Unable to assess

Technicality of language: Lay language was used with minimal medical terminology.

Lexical density: 42%. Calculated from the script for the program voice‐over.

Factual content: Unable to assess

Evaluation of comparator: Ventolin PIL

Metadiscourse: The purpose of the leaflet was stated as providing information about ventolin for the user. The sections contained in the leaflet were also listed at the beginning.

Headings: Headings were present, clearly formatted and clearly signposted the information contained in each section.

Lexical density: 46%. The lexical density was calculated from the "how to use your inhaler" section of the leaflet.

Factual content: The source and evidence base for the information contained in the leaflet was not stated. However, the leaflet included the date it was created/updated.

Inadequate information was provided on which to base an assessment of the verbal support provided.

Kato 2008

Description of intervention:

Name of program: Re‐Mission

Country of origin: USA

Language: English, Spanish and French

Year program used in the study was produced: 2006

Stated expertise of content developers: Scientific and medical consultants contributed to the content of the game.

Stated expertise of program developers: Video game developers and animators were involved in the construction of the video game.

Availability: A trailer of the game can be viewed on the website www.re‐mission.net and the game can be ordered in CD or DVD format from the website. It is available free of charge.

Purpose: To improve health‐related behaviours such as treatment adherence, cancer‐related self‐efficacy and knowledge in adolescents and young adults with malignancies.

Tenor: Developed by health professionals for patients.

Target audience: Adolescents and young adults with a diagnosis of a malignancy.

Format: Video game for personal computer

Hardware required: Computer

Media: Text, audio and animation.

Delivery: Played on computers supplied to the patients in the patient's own home.

Time point of delivery: Patients had been diagnosed with cancer and commenced their treatment regimes.

Success at reaching target audience: 13% of the intervention group did not use their computer or attempt to play the game at all (compared with 9% of the control group).

Assistance: None

Interactivity: Fully interactive

Tailoring: No

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

A commercial PC game (Indiana Jones and the Emperor's Tomb) was used as it had similarities with the "play structure and controller interface" of Re‐Mission.

Evaluation of intervention:

Generic structure: From the information available, the game contains at least four moves: Summary of use; Account of side effects; Constraints on patient behaviour and Outline of benefits.

Rhetorical elements: Users are given audio instructions and suggestions throughout the mission. The main rhetorical elements in the game are to inform and instruct.

Tenor: Health professional to patient. The mission briefing is given by a doctor who outlines the assignment.

Metadiscourse: At the beginning of each mission users are provided with a briefing of their assignment and a list of objectives that they need to complete in order to be successful in the mission.

Technicality of language: Medical terminology is used but defined.

Lexical density: Unable to assess

Evaluation of comparator:

Not applicable

Kinnane 2008

Source of information about intervention: Information provided by the authors in the published study as well as a copy of the DVD.

Description of intervention: Video about chemotherapy, its side effects and how to prevent and manage these side effects given as well as standard pre‐chemotherapy education.

Name of program: Staying well during chemotherapy

Country of origin: Australia

Language: The video is available in 12 languages. Only the English version was used for this study

Year program used in the study was produced: 2005

Stated expertise of program developers: Video was filmed and produced by LOTE Marketing

Process of development and testing: No information was provided other than that the video was developed by oncology nurses with input from the organisations listed above.

Availability: Not reported

Target audience: Patients about to start chemotherapy

Format: DVD

Hardware required: Television and DVD player

Media: Video with audio voice‐over

Delivery: Patients watched the video, with family members who were present on the day, in a separate room of the treatment centre

Length of program: 10 minutes and 30 seconds

Number of times program was used: Once

Time point of delivery: Prior to starting chemotherapy

Success at reaching target audience: All participants viewed the computer program on site at the treatment centre

Assistance: No medical or nursing staff were present during the video.

Interactivity: No

Tailoring: No

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

Standard care

Standard pre‐chemotherapy education consisting of a one hour education session with a member of the nursing staff and written information.

Evaluation of intervention:

Rhetorical elements: The main rhetorical elements in the video are to inform and instruct. Instructions are clear and consistently identify whose role it is to perform the task.

Tenor: The health professional to patient relationship is not stated explicitly but is implied by the language e.g. "during our care for you".

Metadiscourse: The purpose of the video is stated in the introduction which also outlines the main topics of information that will be presented.

Headings: None

Technicality of language: Medical terminology was largely avoided. However, where it was used, it was accompanied by an explanation.

Lexical density: 51%. Calculated from the first three minutes of the video.

Evaluation of comparators:

Rhetorical elements: Unable to assess

Tenor: Nurse to patient

Metadiscourse: Unable to assess

Headings: Unable to assess

Technicality of language: Unable to assess

Lexical density: Unable to assess

Factual content: Unable to assess

Format: One‐hour standardised education session given by a nurse and written information including a Neutropenic Alert card

Knoerl 1999

Source of information about intervention: Information provided by the authors in the published study.

Description of intervention: Instructional video about the use of PCA

Name of program: Not reported

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Not reported

Stated expertise of program developers: Not reported

Process of development and testing: Not reported

Relationship between developers and users: Not reported

Availability: Not reported

Purpose: To provide preoperative teaching regarding the use of PCA therapy that increases patient knowledge about PCA and corrects mistaken beliefs about pain medicine.

Content: Not reported

Target audience: Patients undergoing a surgical procedure who are expected to use PCA postoperatively.

Format: Videotape

Hardware required: Television and VCR

Media: Video with audio

Delivery: The video was viewed in the Ambulatory Surgical Unit prior to the patients going to theatre.

Length of program: 11 minutes

Number of times program was used: Once

Time point of delivery: Patients viewed the video preoperatively and started PCA in the immediate postoperative period.

Success at reaching target audience: All participants viewed the presentation on site.

Assistance: Not reported

Interactivity: No

Tailoring: No

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

Usual care: informal teaching provided by hospital medical staff about PCA as part of usual perioperative care.

Evaluation of intervention:

Inadequate information was provided on which to base an assessment

Evaluation of comparator:

Not applicable

Lirsac 1991

Source of information about intervention: Information provided by the authors in the published study.

Description of intervention: Video about the use of MDIs

Name of program: Not reported

Country of origin: France

Language: French

Year program used in the study was produced: Not reported

Stated expertise of content developers: Not reported

Stated expertise of program developers: Not reported

Process of development and testing: Not reported

Relationship between developers and users: Not reported

Availability: Not reported

Purpose: To demonstrate correct use of MDIs.

Content: Described the use of MDIs

Target audience: Patients prescribed MDIs.

Format: Videotape

Hardware required: Television and VCR

Media: Video with audio

Delivery: Not reported. However, the article implied that the video was viewed on site.

Length of program: Five minutes

Number of times program was used: Once

Time point of delivery: Patients were regular users of MDIs prior to viewing the video.

Success at reaching target audience: All participants viewed the presentation on site.

Assistance: Not reported

Interactivity: No

Tailoring: No

Source of information about comparators: Information provided by the authors in the published study.

Description of comparator: Instruction sheet read by a doctor while participants looked at pictorial representations. Education lasted three to four minutes.

Evaluation of intervention:

Inadequate information was provided on which to base an assessment

Evaluation of comparators:

Inadequate information was provided on which to base an assessment

Mazor 2007

Source of information about intervention: Copy of the videotape as well as information provided by the authors in the published study.

Description of intervention: Video showing a physician‐patient encounter about oral anticoagulant medication management.

Name of program: Patients' views about anti‐coagulation therapy: A research study

Country of origin: USA

Language: English

Year program used in the study was produced: 2005

Stated expertise of content developers: Health professionals

Stated expertise of program developers: Not reported

Relationship between developers and users: Health professional to patient

Availability: Not reported

Purpose: To educate patients on anticoagulant medication using different methods (narrative evidence, statistical evidence or both) to communicate evidence to patients.

Target audience: Patients taking anticoagulant medications.

Format: Videotape

Hardware required: Television and VCR

Media: Video with audio

Delivery: Video was watched in the participant's home.

Length of program: Not reported

Number of times program was used: Patients were asked to view the video once, but were free to watch it as many times as they liked.

Time point of delivery: Patients had been prescribed warfarin and receiving care at an anticoagulation clinic for at least three months.

Assistance: None

Interactivity: No

Tailoring: No

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

Usual care: participants did not receive a video or other form of education as part of this study.

Evaluation of intervention:

Generic structure: The content of the video contained seven moves. The three moves not included were contraindications, outline of benefits and storage instructions.

Rhetorical elements: The majority of the video's content informed users about warfarin and its use.

Tenor: The video consists of a conversation between a doctor and patient. The person viewing the video is instructed to imagine that the doctor in the video is talking to them.

Metadiscourse: Patients are told that they are about to see a video of a doctor and patient talking about warfarin. However, the purpose of the video is not presented.

Headings: None

Technicality of language: Medical terminology was avoided or used with accompanying explanations

Lexical density: 43%. Calculated from the script for the video.

Format: Videotaped conversation between a doctor and patient

Evaluation of comparators:

Not applicable.

McElnay 1989

Source of information about intervention: Information provided by the authors in the published study.

Description of intervention: Video about the use of MDIs

Name of program: Not reported

Country of origin: UK

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: The video was developed by the study authors who were health professionals.

Stated expertise of program developers: The Audio‐Visual Unit at The Queen's University of Belfast.

Relationship between developers and users: Developed by health professional for patients

Availability: Not reported

Purpose: To demonstrate the correct use of the metered dose bronchodilator inhaler.

Target audience: Adults who have been prescribed a metered dose inhaler.

Format: Videotape

Hardware required: Television and VCR

Media: Video with audio

Delivery: The video was viewed on site.

Length of program: Five minutes

Number of times program was used: Once

Time point of delivery: The participants in this study were healthy volunteers who had no previous experience in the use of MDIs

Success at reaching target audience: All participants viewed the video on site.

Assistance: Not reported

Interactivity: No

Tailoring: No

Description of comparators:

1. Ventolin PIL

Written instruction consisting of the drug manufacturer's (Allen & Hanbury) PIL for Ventolin.

2. Personal instruction

Evaluation of intervention:

Generic structure: The program illustrated six steps involved in correct MDI use. It therefore only contained the "Dosage instructions" move.

Rhetorical elements: Unable to assess

Tenor: Unable to assess

Metadiscourse: Unable to assess

Headings: Unable to assess

Technicality of language: Unable to assess

Lexical density: Unable to assess

Factual content: Unable to assess

Format: A short five minute video demonstrating correct MDI use.

Evaluation of comparators:

Evaluation of the PIL presented in Goodyer 2006.

Inadequate information was provided on which to base an assessment of the personal instruction provided.

Navarre 2007

Source of information about intervention: The current version of the tutorial available online as well as information provided by the authors in the published study.

Description of intervention:

Name of program: Metered Dose Inhalers

Country of origin: USA

Language: English

Year program used in the study was produced: 2000

Stated expertise of content developers: Faculty at the University of Michigan College of Pharmacy.

Process of development and testing: Not reported

Relationship between developers and users: Health professional to patient

Availability: The tutorial was also created for access through a website and information regarding the website is available from Dr Erickson at the University of Michigan

Purpose: To demonstrate the correct use of MDIs

Content: The tutorial covers the steps of inhaler technique

Target audience: Adults using MDIs

Format: Computer program available over the Internet or on CD‐ROM.

Hardware required: Computer

Media: Text, video of an actor‐patient and animation

Delivery: Viewed on computers on site at either the clinic or pharmacy.

Length of program: Not reported

Number of times program was used: Once

Time point of delivery: At least six months after commencing inhaler.

Success at reaching target audience: All participants viewed program on site.

Assistance: The research assistant oriented the patient on the use of the computer and was available to answer any question regarding navigation through the program.

Interactivity: Not reported

Tailoring: Not reported

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

Usual care: the participants did not receive any education as part of this study.

Evaluation of intervention:

Generic structure: 15 steps outlining the correct use of an MDI. The content is limited to the "Dosage instructions" move.

Rhetorical elements: The program provides instructions but also informs users of why the action is important and the consequences of performing the action incorrectly.

Metadiscourse: There is no information provided regarding the purpose of the program other than the title stating that it is part of the inhaler instructional series.

Headings: Each step is shown with a heading. Selecting the heading then takes you to another page where information about that step is presented

Lexical density: 45%. Calculated from the first two sections, containing nine of the 15 steps.

Factual content: The authors of the program were identified and the year in which the program was developed was presented as part of the copyright.

Evaluation of comparators:

Not applicable.

Neafsey 2002

Description of intervention: Computer program about the interaction between prescription medications and over‐the‐counter medications and alcohol.

Name of program: Preventing Medicine Conflicts

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Pharmacologist, visual communications designer and design students

Stated expertise of program developers: Animations were produced by a professional visual communications designer using Adobe Illustrator and Aftereffects.

Relationship between developers and users: Developed by health professionals for patients

Availability: The program can be purchased from the University of Connecticut School of Nursing

Purpose: To teach older adults about potential drug interactions that can results from self‐medication with over‐the‐counter agents and alcohol

Content: Information about potential interactions between prescribed medications with over‐the‐counter medications and alcohol.

Target audience: Older adults (aged 60 or over) living independently in the community

Format: CD‐ROM using Macromedia Authorware software

Hardware required: Notebook computers with infra‐red touch‐screen

Media: Text, still graphics and animations (no audio).

Delivery: Viewed on computers provided at the participating senior centre clinics

Length of program: 80 minutes

Number of times program was used: Once

Time point of delivery: Participants were already taking prescription medications in conjunction with OTC preparations.

Success at reaching target audience: All participants viewed the computer program on site

Assistance: Not reported

Tailoring: None

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

1. Written information

2. No information

The control group did not receive any education as part of this study.

Evaluation of intervention:

Rhetorical elements: Unable to assess

Tenor: Unable to assess

Metadiscourse: Unable to assess

Headings: Headings are used in the program. The information hierarchy and placement of elements on the page were tested with participants during development of the program.

Lexical density: Unable to assess.

Factual content: Unable to assess

Evaluation of comparators:

Inadequate information was provided on which to base an assessment

Neafsey 2001

Source of information about comparators: Information provided by the authors in the published study.

Description of comparators:

The control group did not receive any education as part of this study.

Olver 2009

Source of information about intervention: Copy of the CD‐ROM and information provided by the authors in the published study.

Description of intervention: CD‐ROM

Name of program: Understanding cancer

Country of origin: Australia

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Health professionals including oncologists and psychologists

Stated expertise of program developers: The CD‐ROM was developed with media producers Steve Whitham Media and M‐Plex Multimedia

Process of development and testing: The CD‐ROM was designed using the "medical expertise of the researchers in association with local media expertise".

Relationship between developers and users: Developed by health professionals for patients.

Availability: Not reported

Purpose: To provide chemotherapy treatment information as part of the informed consent process

Target audience: Adults who are about to start chemotherapy

Format: CD‐ROM using Macromedia software

Hardware required: Computers

Media: Text, still graphics, video and audio

Delivery: Viewed on computers provided on site at the Chemotherapy Day Centre. Participants were also able to take the CD‐ROM home for further viewing.

Length of program: Depends on which sections of program the user chooses to view

Number of times program was used: Viewed on one occasion on site and then at the participant's discretion off site

Time point of delivery: Prior to starting chemotherapy

Success at reaching target audience: All participants viewed CD‐ROM on site, 36.2% viewed the CD‐ROM again at home

Assistance: A nurse was available on site to help with navigation if participants were unfamiliar with the technology

Interactivity: Limited. patients are able to view components of the program in their entirety or choose particular areas that they are interested in viewing.

Tailoring: Yes ‐ patients can select from a menu the type of cancer they have been diagnosed with. They are then presented with information specific to that cancer and its treatment.

Source of information about comparators: Information provided by the authors in the published study.

Description of comparators:

Written information consisting of the hospital's standard information sheet and consent form.

Evaluation of intervention:

Generic structure: All of the moves except for "Dosage instructions", "Contraindications" and "Storage instructions" were included in the program.

Headings: Headings are used consistently throughout the program and are used to aid navigation.

Evaluation of comparators:

Inadequate information was provided on which to base an assessment

Osguthorpe 1983

Source of information about intervention: Information provided by the authors in the published study.

Description of intervention: Video about medications used to treat psychiatric illnesses

Name of program: Videotaped Nurse Explanation

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Script was developed by the study investigators (nurses)

Stated expertise of program developers: The hospital's audiovisual department

Process of development and testing: The script was developed by the investigators and the video produced in the hospital's audiovisual department. No testing was reported

Relationship between developer and user: Health professional to patient.

Availability: Not stated

Purpose: To provide patients with general information about study medications

Target audience: Psychiatric inpatients

Format: Videotape

Hardware required: Television and VCR

Media: Video, Audio, Text and Cartoons

Delivery: Viewed in a conference room on the hospital ward

Length of program: Eight minutes

Number of times program was used: Once

Time point of delivery: Patients had started the medication within 3 weeks before watching the video

Success at reaching target audience: All participants viewed the presentation on site.

Assistance: Not reported

Interactivity: No

Tailoring: No

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

Evaluation of intervention:

Rhetorical elements: Unable to assess

Tenor: Nurse to patient.

Metadiscourse: Unable to assess

Headings: Unable to assess

Technicality of language: Unable to assess

Lexical density: Unable to assess

Factual content: Unable to assess

Evaluation of comparators: Drug information sheet

Rhetorical elements: Unable to assess

Tenor: Unable to assess

Metadiscourse: Unable to assess

Headings: Unable to assess

Technicality of language: Materials were aimed at fifth grade reading level with important medical symptoms translated into layman's terms.

Lexical density: Unable to assess

Factual content: Unable to assess

Format: The information sheet was constructed so that it could be folded into billfold size and carried easily

Powell 1995

Source of information about intervention: Information provided by the authors in the published study.

Description of intervention:

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Not reported

Stated expertise of program developers: "The videotapes were produced by a national medical media company."

Process of development and testing: Not reported

Availability: Not reported

Relationship between developers and users: Not reported

Purpose: To enhance compliance with prescribed drug therapy.

Target audience: Adults who have been prescribed benazepril, metoprolol, simvastatin or transdermal oestrogen.

Format: Videotape

Hardware required: Television and VCR

Media: Video with audio

Delivery: In the participant's home.

Length of program: Approximately 30 minutes.

Number of times program was used: Not recorded

Time point of delivery: Participants had already been prescribed the medications.

Assistance: None

Interactivity: No

Tailoring: No

Source of information about comparators: Information provided by the authors in the published study.

Description of comparators:

The control group did not receive any education as part of this study.

Evaluation of intervention:

Generic structure: Based on the information provided by the authors the content included at least four moves: Summary of use; Account of side effects; Contraindications and Outline of benefits.

Rhetorical elements: Unable to assess

Tenor: Unable to assess

Metadiscourse: Unable to assess

Headings: Unable to assess

Technicality of language: Unable to assess

Lexical density: Unable to assess

Factual content: Unable to assess

Format: Videotapes of approximately 30 minute duration.

Evaluation of comparators:

No applicable.

Savage 2003

Source of information about intervention: Information provided by the authors in the published study and a copy of the voice‐over script for the English version of the program,

Description of intervention: Multimedia program about metered dose inhaler technique. This study used the English version of the program used in Goodyer 2006.

Name of program: Multimedia Touch Screen System (MTS)

Country of origin: England

Language: English (the program is also available in other languages).

Year program used in the study was produced: Not reported

Stated expertise of content developers: Pharmacy Practice Group King's College London.

Stated expertise of program developers: Not reported

Process of development and testing: Not reported other than to state that content was based on the "how to use your inhaler" section of the Ventolin PIL.

Relationship between developers and users: Health professionals to patients

Availability: No longer available

Purpose: To demonstrate correct inhaler technique

Content: The program covered the eight "key information points" on correct inhaler technique that are included in the Ventolin PIL provided by the drug manufacturer Allen & Hanburys.

Target audience: Adults using bronchodilator MDIs.

Format: Computer program

Hardware required: Multimedia touch screen computer

Media: Video, audio and text.

Delivery: Viewed on computers on‐site.

Length of program: Not reported

Number of times program was used: Once

Time point of delivery: Patients were longstanding users of bronchodilators

Success at reaching target audience: All participants viewed the program on site.

Assistance: Patients were supervised when viewing the program. The authors state that "using the touch screen was easy, with few people of any age required even minimal prompting"

Interactivity: Limited. Users interacted with the computer through a touch screen which allowed some control of navigation through the program

Tailoring: None

Description of comparator:

Written instruction consisting of the drug manufacturer's (Allen & Hanbury) PIL for Ventolin.

Evaluation of intervention:

Evaluation of the multimedia program is presented in Goodyer 2006.

Evaluation of comparators:

Evaluation of the PIL is presented in Goodyer 2006.

Schnellinger 2010

Source of information about intervention: Information provided by the authors in the published study.

Description of intervention: Animated video about appropriate use of antibiotics.

Name of program: Not reported

Country of origin: USA

Language: English.

Year program used in the study was produced: Not reported

Stated expertise of content developers: Study researchers including paediatricians.

Stated expertise of program developers: Eight Point Productions was hired to produce and edit the video.

Relationship between developers and users: Health professionals to patients

Availability: Not reported

Purpose: To educate parents about appropriate use of antibiotics.

Content: Information about the appropriate use of antibiotics.

Target audience: Parents

Format: Video

Hardware required: DVD player

Media: Video animations with audio

Delivery: Viewed on a portable DVD player in the emergency department.

Length of program: Three minutes

Number of times program was used: The video was viewed once with no opportunity to review it.

Time point of delivery: During presentation to the emergency department for acute care.

Assistance: Not reported

Interactivity: None

Tailoring: None

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

Evaluation of intervention:

Inadequate information was provided on which to base an assessment.

Evaluation of comparator:

Inadequate information was provided on which to base an assessment.

Schwarz 2008a

Source of information about intervention: Information provided by the authors in the published study and in response to request for specific information as well as a copy of the script.

Description of intervention: Computer program about emergency contraception (EC)

Name of program: EC Video Doctor

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Study author who is a specialist in women's reproductive health.

Stated expertise of program developers: Study authors oversaw the programming.

Process of development and testing: The program was pilot tested with women seeking urgent care until it was "bug free".

Relationship between developers and users: Health professionals to patients

Availability: Not reported

Purpose: To educate women of child‐bearing age about EC

Target audience: Women of child‐bearing age.

Format: Computer program

Hardware required: Computer

Media: Short video segments, graphics and audio.

Delivery: In two separate Urgent Care Clinics where the women were attending appointments.

Length of program: 15 minutes

Number of times program was used: Once, with the participant having to use all parts of the program.

Time point of delivery: The program was shown to the participants after which they were given a sample pack of EC for them to use in the future if required.

Success at reaching target audience: All participants used the computer program on site

Assistance: Short introductory video instructed users on how to use the mouse to click on each of the nine questions.

Interactivity: Limited. Participants could select any of the nine section in any order but had to watch all of them before they could complete the program.

Tailoring: No

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

The control group viewed a computer program about preconception folate supplementation presented using the same format as the EC program.

Evaluation of intervention:

Metadiscourse: The purpose of the program is stated in the introduction

Headings: Unable to assess

Technicality of language: The authors aimed for a seventh grade reading level and provided an audio voice‐over so that the program could be used in non‐literate populations.

Lexical density: 51%. Calculated from the script.

Factual content: Unable to assess

Evaluation of comparators:

The computer program was the same as that in the intervention arm except that it provided information about preconception folate instead of emergency contraception.

Self 1983

Source of information about intervention: Information provided by the authors in the published study.

Description of intervention: Video about MDI use

Name of program: Not reported

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Pharmacists and Medical Practitioners

Stated expertise of program developers: Technical assistance in videotape production was provided by two individuals from Memphis University School.

Process of development and testing: Not reported other than to state that the video was produced by the investigators.

Relationship between developers and users: Health professional to patient.

Availability: Not reported

Purpose: To demonstrate the correct use of inhalers.

Content: The video provided instructions based on ten steps for the correct use of an inhaler.

Target audience: Adults with an asthma diagnosis who use inhalers.

Format: Videotape

Hardware required: Television and VCR

Media: Video

Delivery: The video was viewed in an allergy clinic.

Length of program: Not reported

Number of times program was used: Once

Time point of delivery: 12/29 had previously used inhalers but had not seen a demonstration of proper technique. The others were starting an inhaler for the first time.

Success at reaching target audience: All participants viewed the presentation on site.

Assistance: Not reported

Interactivity: No

Tailoring: No

Source of information about comparators: Information provided by the authors in the published study.

Description of comparators:

1. Written information

An information sheet "reflecting the manufacturer's directions and the current literature".

2. Personal instruction

Personal instruction in the use of an inhaler by a pharmacist.

Evaluation of intervention:

Inadequate information was provided on which to base an assessment.

Evaluation of comparators:

Inadequate information was provided on which to base an assessment.

Solomon 1988

Source of information about intervention: Information provided by the authors in the published study.

Description of intervention: Video about tetracycline for treatment of STDs

Name of program: So they gave me these pills...

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Developed by the authors.

Stated expertise of program developers: Not reported

Process of development and testing: Video was developed by the authors.

Relationship between developer and user: Health and educational professionals to patients.

Availability: Copies of the video are available from the project officer at the Centre for Disease Control.

Purpose: To provide instructions on the correct administration of tetracycline for STD.

Format: Videotape

Hardware required: Television and VCR

Media: Video and audio

Delivery: The video was viewed in the STD clinic.

Length of program: 10 minutes

Number of times program was used: Once

Time point of delivery: Patients viewed the video on the day they commenced their medication.

Success at reaching target audience: All participants viewed the video on site.

Interactivity: No

Tailoring: No

Source of information about comparators: Information provided by the authors in the published study.

Description of comparators:

Patients in both the intervention and control group were randomised to receive either special pill packaging or usual care:

1. Special pill packaging

2. Usual care (verbal instructions)

Evaluation of intervention:

Rhetorical elements: The video primarily instructs patients on the correct use of tetracycline as well as informing them of the consequences of improper use.

Tenor: Doctor to patient "a physician/narrator speaks directly to patients" and also patient to patient "testimonials from a young couple" who have taken the medication

Metadiscourse: Unable to assess

Headings: Unable to assess

Technicality of language: The physician/narrator "uses easy to understand language and concrete illustrations"

Lexical density: Unable to assess

Factual content: Unable to assess

Evaluation of comparator: Verbal instructions given in the usual care group.

Rhetorical elements: Seven of the nine sentences instruct the patient while the other two inform. Instructions used the imperative form and responsibility for the actions was clear.

Tenor: Doctor to patient.

Metadiscourse: None.

Headings: Not applicable.

Technicality of language: Language does not contain any technical or medical terminology.

Lexical density: 53%

Factual content: The source and evidence base for the content was not given but the content consisted primarily of dosing instructions.

Format: Short paragraph read by a doctor to the patient.

Stone 1989

Source of information about intervention: Information provided by the authors in the published study.

Description of intervention: Video about anticoagulant therapy

Name of program: Not reported

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Produced by the study authors

Stated expertise of program developers: Not reported

Process of development and testing: The video was produced by the study authors but no information was provided about its development or testing

Relationship between developers and users: Health professional to patient

Availability: Not reported

Purpose: To teach patients starting anticoagulant medications about anticoagulant therapy

Content: The videotape reviewed the reasons for anticoagulant therapy, the complications of warfarin, how to monitor therapy and other general points about anticoagulant therapy

Target audience: Patients starting treatment with anticoagulants

Format: Videotape

Hardware required: Television and VCR

Media: Video and audio

Delivery: The video was viewed at the anticoagulation clinic

Length of program: 15 minutes

Number of times program was used: Once

Time point of delivery: Prior to starting anticoagulant medication

Success at reaching target audience: All participants viewed the video on site

Assistance: Not reported

Interactivity: No

Tailoring: No

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

Personal instruction

Lecture from one of two nurses specially trained in anticoagulation therapy. The nurse lecture was standardised and contained the same information as the videotape.

A question and answer session with a health professional was held following both the video and personal instruction.

Evaluation of intervention:

Rhetorical elements: Unable to assess

Tenor: Unable to assess

Metadiscourse: Unable to assess

Headings: Unable to assess

Technicality of language: Unable to assess

Lexical density: Unable to assess

Factual content: Unable to assess

Format: 15 minute videotape

Evaluation of comparators:

Rhetorical elements: Unable to assess

Tenor: Nurse to patient

Metadiscourse: Unable to assess

Headings: Unable to assess

Technicality of language: Unable to assess

Lexical density: Unable to assess

Factual content: Unable to assess

Format: Standardised lecture given by one of two nurses

Trent 2010

Source of information about intervention: Copy of the video and information provided by the authors in the published study.

Description of intervention: Video about self‐care of PID in addition to standardised care.

Name of program: Pelvic inflammatory disease ‐ patient education video

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported but copyright at the end of the video was from 2005.

Stated expertise of content developers: Developed by the authors who are adolescent health specialists.

Stated expertise of program developers: The program was "created by a professional production team"

Relationship between developer and user: Health professionals to patients.

Availability: Publicly available on "YouTube"

Purpose: To educate patients about PID self‐care in order to improve adherence

Target audience: Adolescent girls diagnosed with PID.

Format: Not reported

Hardware required: Not reported

Media: Video and audio with some simple diagrams and animations.

Delivery: The video was viewed at the clinical sites.

Length of program: Six minutes

Number of times program was used: Once

Time point of delivery: Patients viewed the video on the day they were diagnosed and prior to being discharged with a course of the medication.

Success at reaching target audience: All participants viewed the video on site.

Assistance: Not reported

Interactivity: No

Tailoring: No

Source of information about comparator: Information provided by the authors in the published study.

Evaluation of intervention:

Generic structure: The content included five moves: Summary of use; Dosage instructions; Constraints on patient behaviour; Outline of benefits and Clinical contact available.

Rhetorical elements: The program predominantly informed patients but specific instructions were also provided in the final minute of the video.

Tenor: Patient to patient. However, actors were used rather than actual patients. A doctor was also shown but directed their conversation to the patient/actor.

Headings: None

Technicality of language: Medical terminology was used infrequently and when used, was accompanied by an explanation.

Lexical density: 36%. Calculated from the first minute of the video.

Format: Six minute video showing actors speaking directly to camera accompanied by a few simple diagrams and animations.

Evaluation of comparators:

Inadequate information was provided on which to base an assessment

Van Der Palen 1997

Source of information about intervention: Information provided by the authors in the published study.

Description of intervention: Video about the use of MDIs

Name of program: Not reported

Country of origin: Netherlands

Language: Dutch

Year program used in the study was produced: Not reported

Stated expertise of content developers: The videos were not designed for this study but were "readily available from various pharmaceutical companies"

Stated expertise of program developers: Not reported

Process of development and testing: Not reported

Relationship between developer and user: Not reported

Availability: The videos were available from the pharmaceutical companies at the time of the study

Purpose: To instruct patients on correct inhaler technique

Content: Not reported

Target audience: Patients using MDIs

Format: Videotape

Hardware required: Television and VCR

Media: Video and audio

Delivery: In the participant's home

Length of program: Not reported

Number of times program was used: Patients watched it a median of three times (range one to 50)

Time point of delivery: Patients had been using inhaled medications for at least one month

Success at reaching target audience: Patients were given the video to take home and it was reported that all of them watched it at least once during the study period.

Assistance: None

Interactivity: No

Tailoring: No

Source of information about comparators: Information provided by the authors in the published study.

Description of comparators:

1. Personal instruction

2. Group instruction

3. Control group

The control group did not receive any education as part of this study.

Evaluation of intervention:

Inadequate information was provided on which to base an assessment

Evaluation of comparators:

Inadequate information was provided on which to base an assessment

Voris 1982

Source of information about intervention: Information provided by the authors in the published study which included the script for the educational program.

Description of intervention: Slide‐tape presentation about tricyclic antidepressants

Name of program: The Tricyclic Antidepressant Education Program

Country of origin: USA

Language: English

Year program used in the study was produced: Not reported

Stated expertise of content developers: Developed by the first author (psychiatric pharmacy fellow)

Stated expertise of program developers: Assistance from the Biomedical Communications Department at the University of Nebraska Medical Centre.

Relationship between developers and users: Health professionals to patients.

Availability: Not reported

Purpose: To increase both short‐term and long‐term knowledge about tricyclic antidepressants and depression.

Target audience: Adults who are commencing a tricyclic antidepressants

Format: Slide‐tape audiovisual presentation (either a carousel projector, screen and tape player or a carousel and a cassette playback synchronizer).

Hardware required: Carousel projector, screen and a cassette player.

Media: Text or still graphics and audio

Delivery: Viewed on a projector screen at the hospital.

Length of program: Seven minutes

Number of times program was used: Once

Time point of delivery: Patients had recently commenced a tricyclic antidepressant.

Success at reaching target audience: All participants viewed the presentation on site.

Assistance: The investigator was not present during the program but was available to answer questions at the completion of the presentation.

Interactivity: No

Tailoring: No

Source of information about comparator: Information provided by the authors in the published study.

Description of comparator:

Usual care:

"Information which nurses and physicians decided to give them as part of the usual hospital routine."

Evaluation of intervention:

Tenor: Health professional to patient. The identity of the authors and the intended user was clearly stated at the beginning of the program. The person responsible for actions is stated throughout.

Metadiscourse: There is a clear description of the purpose of the education in the introduction. This outlines what information the education will provide and what it is designed to teach patients.

Headings: Unable to assess

Lexical density: 52%. Calculated from the script for the audiovisual presentation.

Factual content: The institutions involved in developing the content were identified. The script also alluded to some of the information being based on scientific studies.

Format: A seven minute slide‐tape audiovisual presentation

Evaluation of comparator:

Not applicable.

Table 4. Description and evaluation of interventions

Comparison 1. Multimedia education versus usual care or no education

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Knowledge (mean score, %) Show forest plot	6		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 < 4 weeks	6	817	Std. Mean Difference (IV, Random, 95% CI)	1.04 [0.49, 1.58]
1.2 ≥ 4 weeks	1	8	Std. Mean Difference (IV, Random, 95% CI)	1.18 [‐0.42, 2.79]
2 Knowledge (N who improved) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

3 Skill acquisition (mean score, %) Show forest plot	2	94	Mean Difference (IV, Random, 95% CI)	18.32 [11.92, 24.73]

3.1 < 4 weeks	1	34	Mean Difference (IV, Random, 95% CI)	20.90 [9.91, 31.89]
3.2 ≥ 4 weeks	1	60	Mean Difference (IV, Random, 95% CI)	17.0 [9.12, 24.88]
4 Compliance with medication (% who complied) Show forest plot	2	4552	Risk Ratio (M‐H, Random, 95% CI)	1.02 [0.96, 1.08]

4.1 < 4 weeks	1	306	Risk Ratio (M‐H, Random, 95% CI)	1.00 [0.95, 1.05]
4.2 ≥ 4 weeks	1	4246	Risk Ratio (M‐H, Random, 95% CI)	1.04 [0.97, 1.11]
5 Compliance with monitoring (% who complied) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

5.1 ≥ 4 weeks	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
6 Pain rating (mean score, range 0 to 10) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

7 Risk of drug abuse (mean score) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

8 Satisfaction with care (mean score) Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Totals not selected

8.1 < 4 weeks	2		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
9 Perception of care (mean score) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

10 Self‐efficacy (mean score) Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Totals not selected

10.1 < 4 weeks	2		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
11 Beliefs about medication (mean score, range 1 to 5) Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Totals not selected

12 Beliefs about medication (N who answered correctly) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

13 Perception of the education (N who learnt something new) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

Comparison 1. Multimedia education versus usual care or no education

Comparison 2. Multimedia education versus written education

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Knowledge (N who improved) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

2 Skill acquisition (mean score, %) Show forest plot	1	20	Mean Difference (IV, Random, 95% CI)	31.0 [10.15, 51.85]

3 Skill acquisition (N who improved) Show forest plot	2	164	Risk Ratio (M‐H, Random, 95% CI)	2.14 [1.33, 3.44]

4 Beliefs about medication (N who would not inappropriately request Rx) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

5 Perception of the education (N who learnt something new) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

Comparison 2. Multimedia education versus written education

Comparison 3. Multimedia education versus education by a health professional

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Knowledge (mean score, %) Show forest plot	1	22	Mean Difference (IV, Random, 95% CI)	‐2.20 [‐8.83, 4.43]

2 Skill acquisition (mean score, %) Show forest plot	4		Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 < 4 weeks	3	130	Mean Difference (IV, Random, 95% CI)	‐1.01 [‐15.75, 13.72]
2.2 ≥ 4 weeks	2	130	Mean Difference (IV, Random, 95% CI)	‐4.29 [‐17.23, 8.65]
3 Bronchial obstruction (FEV, litres) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

Comparison 3. Multimedia education versus education by a health professional

Comparison 4. Multimedia education versus written education and education by a health professional

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Skill acquisition (N who improved) Show forest plot	1	69	Risk Ratio (M‐H, Random, 95% CI)	1.17 [0.70, 1.94]

Comparison 4. Multimedia education versus written education and education by a health professional

Comparison 5. Multimedia education versus control multimedia

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Knowledge (mean score, %) Show forest plot	2	568	Mean Difference (IV, Random, 95% CI)	2.78 [‐1.48, 7.05]

2 Skill acquisition (mean change score, %) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 < 4 weeks	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 ≥ 4 weeks	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3 Compliance with medication (mean score, range 18‐90) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

3.1 ≥ 4 weeks	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4 Use of medication (N who used medication) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

5 Peak flow reading (litres per second) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

6 Self‐efficacy (mean score, range 27 to 189) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

7 Quality of life (mean score) Show forest plot	1	269	Std. Mean Difference (IV, Random, 95% CI)	0.20 [‐0.04, 0.44]

7.1 Age < 18	1	221	Std. Mean Difference (IV, Random, 95% CI)	0.17 [‐0.09, 0.44]
7.2 Age 18 and over	1	48	Std. Mean Difference (IV, Random, 95% CI)	0.31 [‐0.26, 0.88]
8 Beliefs about medication (N with more positive beliefs) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

9 Perceived stress (mean score, range 10 to 50) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

Comparison 5. Multimedia education versus control multimedia

Comparison 6. Mulitmedia education and a co‐intervention versus co‐intervention alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Knowledge (mean score, %) Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 < 4 weeks	2	380	Mean Difference (IV, Random, 95% CI)	24.59 [22.34, 26.83]
1.2 ≥ 4 weeks	1	60	Mean Difference (IV, Random, 95% CI)	23.20 [12.82, 33.58]
2 Skill acquisition (mean score, %) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3 Non‐compliance (mean score, range 0 to 160) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

4 Compliance with medication (N) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

5 Compliance with follow‐up (N) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

6 Medical complication (N) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

7 Adverse medication behaviour (mean score, range 0‐40) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

7.1 < 4 weeks	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
7.2 ≥ 4 weeks	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
8 Self‐efficacy (mean score, range 0 to 5) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

8.1 < 4 weeks	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
8.2 ≥ 4 weeks	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 6. Mulitmedia education and a co‐intervention versus co‐intervention alone