Purpose. Entertainment education is the process of purposely designing and implementing media that incorporate educational messages within an entertaining format. Incorporating entertainment education within patient decision aids targeted to patients with limited health literacy may promote user engagement and enhance informed decision making. This study explores the impact of an entertainment-based patient decision aid for prostate cancer screening on user engagement with the program in primary care patients with varied health literacy levels. Methods. We developed a computerized, interactive multimedia patient decision aid for prostate cancer screening, which relied on concepts of entertainment education (ie, soap opera segments) to present the prostate cancer screening decision in an interesting, appealing, and engaging format. The soap opera segments were integrated with interactive learning modules and delivered sequentially followed by celebrity testimonials and a social matching values clarification exercise. Patients from two clinical settings were targeted for the intervention: a high-literacy group from a university-based family medicine clinic (n=148), and a low-literacy group from a general medicine clinic operated by a county health department (n=65). Patients completed a 16-item user engagement measure after completing the program and before seeing a primary care provider. Results. Average patient age was 56 years. In the high-literacy setting, 68% of patients were college graduates; in the low-literacy setting, 76% had a high school education or less. Overall, user engagement was greater among low-literacy patients compared to high-literacy patients (mean on a 100-point scale, 88.7 vs. 79.1, P<.001). Differences on subscales related to the soap opera segments, celebrity testimonials, and values clarification exercise showed the same pattern. Low-literacy patients were more likely to report the characters in the soap opera were similar to them (84% vs. 62%), the story made them think about their friends (84% vs. 61%), the social matching exercise was enjoyable (98% vs. 69%), and their selections in the social matching exercise were a good match for how they felt (94% vs. 76%, all significant at P<.01). Conclusions. The use of entertainment education appears to promote greater engagement in a patient decision aid for prostate cancer screening among patients with limited health literacy compared to other patients. Subsequent research will examine the impact of user engagement on decisional outcomes.