ArticleLiterature Review

The Role of Pictures in Improving Health Communication: A Review of Research on Attention, Comprehension, Recall, and Adherence

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Abstract

To assess the effects of pictures on health communications. Peer reviewed studies in health education, psychology, education, and marketing journals were reviewed. There was no limit placed on the time periods searched. Pictures closely linked to written or spoken text can, when compared to text alone, markedly increase attention to and recall of health education information. Pictures can also improve comprehension when they show relationships among ideas or when they show spatial relationships. Pictures can change adherence to health instructions, but emotional response to pictures affects whether they increase or decrease target behaviors. All patients can benefit, but patients with low literacy skills are especially likely to benefit. Patients with very low literacy skills can be helped by spoken directions plus pictures to take home as reminders or by pictures plus very simply worded captions. Practice implications: Educators should: (1) ask "how can I use pictures to support key points?", (2) minimize distracting details in pictures, (3) use simple language in conjunction with pictures, (4) closely link pictures to text and/or captions, (5) include people from the intended audience in designing pictures, (6) have health professionals plan the pictures, not artists, and (7) evaluate pictures' effects by comparing response to materials with and without pictures.

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... [11][12][13][14] Health messages that incorporate images are processed more efficiently than messages with text alone and are especially important for individuals with low health literacy and/ or numeracy to help explain and retain complicated medical information. [15][16][17] Given the pervasive public stigma surrounding lung cancer and cigarette smoking that is exacerbated by public health communications and ad campaigns, 18 emphasis must be placed on selecting imagery that is engaging to individuals who are eligible for LCS but does not evoke stigma or fear. Recently, the American Cancer Society National Lung Cancer Roundtable published the Lung Cancer Stigma Communications Assessment Tool (LCS-CAT) focused on identifying and providing alternatives for stigmatizing, judgmental, and discriminating language, imagery, and context in lung cancer communications. ...
... And so that, that gives me a very aversive feeling to cigarettes. 17 12 Uh, yeah, the red color is more like urgent more. Um, uh, I think the red color is, is uh, well like a stop sign. ...
... Imagery can be a powerful element of health communication, helping to capture the audience's attention, communicating important information, and even evoking reactions that can motivate or hinder behavior. 17 LCS communications must emphasize selecting appropriate imagery to connect with the eligible population effectively. This study involved a qualitative inquiry approach and participatory research methodology to have LCS-eligible individuals select imagery representing LCS and thematically illuminate representation of imagery in LCS communications. ...
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Introduction Effective communication and messaging strategies are crucial to raise awareness and support participants' efforts to adhere to lung cancer screening (LCS) guidelines. Health messages that incorporate images are processed more efficiently, and given the stigma surrounding lung cancer and cigarette smoking, emphasis must be placed on selecting imagery that is engaging to LCS-eligible individuals. This exploratory study aimed to identify person-centered themes surrounding LCS imagery. Materials and Methods This qualitative study leveraged a modified photovoice approach and interviews to define descriptive themes about LCS imagery. Study participants eligible for annual LCS who had a CT scan within 12 months were asked to select three images and participate in a semi-structured interview about photo selection, likes, and dislikes. Participants were also asked their opinions about images from current LCS communications featuring matches, smoke, and cigarettes. Data were analyzed using an inductive thematic approach. Results Data saturation was reached after thirteen individuals completed the photovoice activity; each participant selected three pictures resulting in a total of 39 images representing LCS. Over half (54%) of images selected contained lungs and only 4 (10%) contained smoking-related elements. Five main themes emerged: 1) images should focus on good news and early detection; 2) people should be relatable; 3) pictures with lungs can dually support lung health or invoke fear; 4) opportunity for education or awareness; and 5) should not be judgmental and induce stigma. Conclusions These findings suggest that LCS imagery should not contain negative or stigmatizing elements but instead be relatable and educational. This information can inform communication and messaging interventions and strategies for future LCS participation, awareness, and educational research.
... Care must also be taken to choose images that reinforce rather than distract from the core message. Finally, selected images must be culturally acceptable, reflecting the target audience and their values [21][22][23]. ...
... The importance of listening to and engaging with communities to address concerns that prompt vaccine hesitancy is also well established [22,23]. Critically, involving representatives of targeted communities as de-signers, creators, and advocates of knowledge translation materials builds trust and credibility in the message [22]. ...
... One challenge in designing educational infographics is how to achieve the right balance between providing sufficient information without overwhelming users with differing levels of health literacy [23]. Most participants of both the survey and focus group reported that the infographics were clear, but some people requested additional information about the studies referenced and on the long-term effects of vaccines. ...
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Introduction: Vaccine hesitancy, including concerns about possible fertility side-effects, caused delay in the uptake of COVID-19 vaccines in Canada and elsewhere. One way of tackling vaccine hesitancy is the use of infographics that explain key issues and address concerns. The aim of this study was to explore the collaborative process of rapidly developing an infographic that was informed by community feedback and tailored to address fertility concerns during urgent COVID-19 pandemic conditions. Methods: A survey promoted through social media and focus group discussion with community contacts were used to iteratively consult target audiences and gather feedback on interpretation of the infographic’s content and meaning. Survey results were analysed using descriptive methods. A focus group discussion was analysed using inductive thematic and sentiment analysis. Feedback guided infographic development. Results: A draft infographic and survey were shared online. 33 of 37 survey respondents expressed that they trusted the information provided in infographics. Survey respondents and focus group participants both wanted simple language and additional information to address concerns about the long-term effect of COVID-19 vaccines on fertility. Opinions indicated that more effort was needed to address varying levels of health literacy within communities. There was conflicting feedback on whether use of inclusive language by removing gender labels and focusing on biology, was helpful or confusing. Conclusions: This study shows public feedback can help tailor content and design of vaccine confidence building tools making them more accessible to the general population. In addition, efforts to resolve specific concerns can be augmented by modifying and/or creating different versions of infographics.
... The 'picture superiority effect' is a proven finding in cognition studies: pictures present better in memory tests than words (Hockley, 2008;Mintzer & Snodgrass, 1999). A study found that the use of visual images linked to written or spoken text can significantly improve attention, recall, and understanding of health information (Brotherstone et al., 2006;Houts et al., 2024). ...
... Some video messages use musical illustrations to increase dramatization, such as the Cath Lab Service information video from the cardiac polyclinic. Images will stimulate the target's emotional response; this response can affect the increase or decrease of behavior on health instructions (Houts et al., 2024). That is why the selection of images/illustrations in health messages is fundamental. ...
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Background: Health promotion is an important part of the health services strategy in hospitals around the world, including in Indonesia. Hospitals can contribute to improving Indonesians’ health by complying with regulations and following government plans. Al Islam Hospital is a type B hospital in Bandung that has adopted diverse health promotion and communication programs. RS Al Islam Bandung is committed to improving the community’s health status through various programs. Purpose: This study aimed to understand how the hospital’s health promotions (PKRS) installation implements advocacy, community empowerment, and partnership programs through communication activities and media. Methods: We employed a qualitative method that included interviews, observation, and a review of relevant literature. Results: The results showed that RS Al Islam Bandung had integrated the principles of effective health communication into its PKRS program. Firstly, hospital management engages in health advocacy by issuing policies in various media that support health promotion programs; secondly, Al Islam Bandung Hospital equips the community with the information, willingness, and skill necessary to tackle the different health issues by involving patients and their families, hospital human resources, and the community; and thirdly, RS Al Islam Bandung establishes collaboration with educational institutions, local communities, and mass media. Conclusion: For the sustainability and effectiveness of health promotion programs, hospitals must ensure continued cooperation with stakeholders and continue to improve their health communication media. Implication: The study suggests that hospital management can conduct a continuous evaluation of health promotion activities carried out at Al Islam Bandung Hospital so that the health promotion and communication activities are not limited to the hospital area. The hospital can achieve this by optimizing its communication media. Hospitals can start using social media analytics and SEO campaigns to produce messages that cater to the needs of their audience.
... Its illustrations provide an intuitive approach for respondents to interpret and respond to questions regarding their daily life postures. According to the literature, visuals improve comprehension in 98% of studies, enabling the respondents to better understand and process complex information [29,30]. Mayer's cognitive theory of multimedia learning supports the notion that combining images with text activates dual channels in the brain, enhancing learning and retention [31]. ...
... The experts unanimously agreed on the relevance of these illustrations, indicating the importance of visuals in ensuring that the respondents fully grasped the intended meaning of each question. This approach is particularly essential for populations with relatively low literacy levels or cognitive difficulties, for whom text alone may present challenges [29]. Hence, visual cues can render questionnaires more accessible and easier to use, improving the overall reliability of the data collected. ...
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Background/Objectives: A proper posture is essential for musculoskeletal health, and a poor posture can lead to low back pain. To address the limitations of traditional text-based questionnaires, this study developed and validated a visualized posture assessment questionnaire for evaluating daily postures related to low back pain. The questionnaire was administered in Taiwan and designed using Traditional Chinese language. Methods: The proposed questionnaire evaluates six categories of daily activities including lifting heavy objects, sitting, putting on shoes, face washing and tooth brushing, getting out of bed, and doing sit-ups, or similar actions. Each category comprises an ergonomic posture and a non-ergonomic posture with corresponding illustrations. The questionnaire was administered to 100 participants, and its internal consistency was evaluated using Cronbach’s α, while test–retest reliability was assessed using intraclass correlation coefficients (ICCs). An expert panel reviewed the content validity, and the item-level content validity index (I-CVI) was calculated for each item and illustration. Results: Testing revealed a Cronbach’s α of 0.808, indicating high internal consistency, and a test–retest reliability, as measured by ICCs, of 0.78, indicating high stability over time. The I-CVI scores were high across all items, with the illustrations unanimously rated by the experts as highly relevant, supporting the effectiveness of the questionnaire’s visualized format for enhanced comprehension. Conclusions: The proposed questionnaire exhibits high reliability and validity, rendering it effective in evaluating posture-related risks of low back pain. This questionnaire also offers a more accessible and intuitive alternative to text-based questionnaires, with potential applications in clinical and research settings.
... Although 64% were in color and 57% included pictures, the graphics and illustrations scored poorly in the SAM evaluation. Visual appeal and incorporation of pictures and infographics have been reported to improve patient attention, comprehension, recall, and adherence especially for patients with low literacy skills, 16,25 but they must be relevant and of good quality. These features may be even more important for a pediatric audience. ...
... However, general guidelines recommend that health educators use simple line drawings or photographs and include captions, which should be representative of the target audience (age, gender, and ethnicity). 11,25 The SAM and PEMAT-P tools do not measure how phosphate educational materials are utilized during a dietetic consultation, 26 such as alongside visual material like ingredient labels, or adapted to ensure it is individualized and patient-centered. Phosphate educational materials are not usually designed to be stand-alone resources but as tools to discuss the setting of shared goals rather than just knowledge acquisition. ...
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Objective: This study aimed to review the quality and content of phosphate educational materials used in pediatric chronic kidney disease. Methods: The quality of text-based (TB) pediatric phosphate educational materials was assessed using validated instruments for health literacy demands (Suitability Assessment of Materials, Patient Education Material Assessment Tool [PEMAT-P]) readability (Flesch Reading Ease, and Flesch-Kincaid Grade Level). Codes were inductively derived to analyse format, appearance, target audience, resource type, and content, aiming for intercoder reliability. 80%. The content was compared to Pediatric Renal Nutrition Taskforce (PRNT) recommendations. Results: Sixty-five phosphate educational materials were obtained; 37 were pediatric-focused, including 28 TB. Thirty-two percent of TB materials were directed at caregivers, 25% at children, and 43% were unspecified. Most (75%) included a production date, with 75% produced .2 years ago. The median Flesch Reading Easetest score was 68.2 (interquartile range [IQR] 61.1-75.3) and Flesch-Kincaid Grade Level was 5.6 (IQR 4.5-7.7). Using Suitability Assessment of Materials, 54% rated ''superior'' ($70), 38% rated ''adequate'' (40-69), and 8% rated ''not suitable'' (#39). Low-scoring materials lacked a summary (12%), cover graphics (35%), or included irrelevant illustrations (50%). Patient Education Material Assessment Tool-P scores were 70% (IQR 50-82) for understandability and 50% (IQR 33-67) for actionability. An intercoder reliability of 87% was achieved. Over half of limited foods are in agreement with PRNT (including 89% suggesting avoiding phosphate additives). Recommendations conflicting with PRNT included reducing legumes and whole grains. Over a third contained inaccuracies, and over two-thirds included no practical advice. Conclusions: TB pediatric phosphate educational materials are pitched at an appropriate level for caregivers, but this may be too high for children under 10 years. The inclusion of relevant illustrations may improve this. Three-quarters of materials scored low for actionability. The advice does not always align with the PRNT, which (together with the inaccuracies reported) could result in conflicting messages to patients and their families.
... These images will provide an appropriate understanding of the questions as well as give better understanding of products that contain alcohol and tobacco. This finding aligned with the review in Peter et al. [25] who mentioned that incorporating pictures alongside text can Fig. 7. Example of areas of concern as identified by participants. significantly improve attention, recall, and comprehension of health information. ...
... Participants suggested that the questions should be provided in lay language to enable patients to understand them better. This finding is in line with [25], who suggested the use of simple language in conjunction with pictures to present information to patients in a way that everyone can understand regardless of their literacy level. ...
... 7,10,11 Theoretical frameworks for developing OPEMs also stem beyond appropriate readability but include imagery or video education to improve understanding and retention of the presented materials. [12][13][14] However, most OPEMs are in the English language and many English and Spanishlanguage OPEMs are not at a recommended readability level. [15][16][17] Currently, there is a lack of literature on the efficacy of reducing healthcare disparities regarding preventative care screenings using Spanish-language OPEMs developed explicitly in a readable, multimedia format. ...
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Background: Breast cancer is the leading cause of death among Hispanic/Latina women. Screening mammograms reduces morbidity and mortality, although Spanish-preferred patients face linguistic barriers, with 61% of patients in an Internal Medicine (IM) clinic being up to date on screenings. The study aimed to increase breast screening rates among Spanish-preferred IM patients by 12% within six weeks using culturally tailored Spanish-language educational materials. Methods: Spanish-preferred patients were identified by language preference, age, and breast cancer screening status. Thirty-six women IM patients (intervention) and twenty-six Family Medicine (FM) patients (control) were selected. The IM patients received a link to a Spanish screening education video via an electronic portal message or mailed letter. If no screening was completed, patients were then called by a native Spanish speaker. FM patients received no intervention. Screening rates were compared to evaluate the efficacy of the video in increasing screening. Results: Nine IM patients were excluded due to relocation or receiving care elsewhere. Post-intervention, screening adherence improved in both groups; the IM group improved by 25.9% (7 patients, P = 0.007) and 15.4% in the FM group (4 patients, P = 0.04). The change was significantly higher in the intervention group, P < 0.001. Conclusion: Providing screening education in Spanish significantly improved adherence. Incorporating culturally tailored education in clinical practice mitigates language-related health disparities and improves screening rates. Further research is needed on a larger scale with education in other languages to determine the effects on screening rates when patients have education in their preferred language.
... The second type, it involves taking into account cultural nuances and customs of the target audience to ensure that the message is accurately conveyed and understood (Chan et al., 2014). The third type, it involves simplifying complex language and concepts to make them more accessible and understandable for the target audience, particularly for those with limited literacy or language proficiency (Houts et al., 2006). The fourth type, this involves adapting the translation to fit the specific cultural and linguistic context of the target audience, including regional variations in language, idioms, and cultural references (Herdman et al., 1998). ...
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Given the disempowered status of translation as is shown in the fact that it is typically regarded or treated as secondary, derivative, and thus inferior, the necessity to further explore ways to empower translation needs to be recognized and reaffirmed. This study aimed at investigating the untranslatability of masculinity, transcultural practice of cultural word-loaded translation, and performative masculinity found in Robert Baden Powell’s Scouting for Boys from English into Indonesian since not all cultural terms in Source Text can be fully transferred into Target Text as well as the translator’s decision to overcome the problem of untranslatability since English and Indonesian have very different cultural concepts. In this qualitative descriptive study, the data in the forms of words, phrases, or sentences denoting performative masculinity have been taken from the book of Robert Baden Powell’s Scouting for Boys. The results show that when the aforementioned study found that the loan word or loan word plus explanation strategy can be used to deal with the problem of untranslatability. Every strategy, procedure, and method offer a solution to translation difficulties, one of which is retaining words from the source text into the target text via transference, naturalization, and notes to untranslatability of masculinity, transcultural practice in cultural word-loaded translation, and performative masculinity. Translation must and can be empowered, and to avoid weak translation, the translator needs to be prepared to engage with complexity and search for better alternatives by relentlessly probing the network of possibilities.
... Low health literacy is associated with worse health outcomes, poorer knowledge of illness, and worse self-management, which impacts individuals' ability to manage HIV and other diagnoses [15][16][17]. Rigorously-designed infographics can counteract these concerns by improving the way information is offered to patients, which can lead to better patient engagement, and improved recall of learned material among other benefits [18][19][20][21]. ...
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We developed an infographic intervention to augment HIV-related education in the Dominican Republic (DR), which demonstrated preliminary success in pilot studies. We then partnered with the United States Agency for International Development’s (USAID) HIV Services and Systems Strengthening program in the DR to scale up the intervention. We used a two-tier Training-of-Trainer (TOT) method to teach intervention administration. N = 12 program leaders completed the tier-1 training and subsequently taught N ~ 102 clinical staff to use infographics with people with HIV (PWH) (tier-2 trainings). Study Aim 1 was to assess implementation outcomes; Aim 2 was to explore infographic influences on program-level health outcomes. We conducted a hybrid type 3 effectiveness-implementation study with three data components: (1) Surveys bookending tier-1 and tier-2 trainings; (2) Focus groups with tier-1 and tier-2 trainees; and (3) program-level data. We designed surveys according to Kirkpatrick’s Training Evaluation Model and analyzed responses with descriptive statistics and/or Fisher’s exact tests. We led four focus groups with a theory-driven guide and analyzed transcripts with conventional qualitative content analysis. We analyzed program-level data by comparing outcomes before and after infographic use with advanced statistical modeling. All 12 program leaders completed tier-1, and 36 staff completed tier-2 surveys; focus groups comprised eight tier-1 and 27 tier-2 trainees; program-level data pertained to 4,318 PWH. Surveys and focus groups indicated the TOT method is feasible, acceptable, and sustainable. Program-level findings showed PWH were more likely to attend scheduled visits and be virally suppressed following infographic implementation. Results indicate our intervention can likely enhance HIV education at large scale.
... Healthcare providers will be reminded of several techniques that enhance self-efficacy during patient interviews, 50 as self-efficacy is found to be a key mediator of patient health behaviour. [51][52][53][54] An infographic will be shared to be used during consultations, in order to induce better processing of health information by the patient, [55][56][57] and to act as a check for health professionals to inform patients about all available treatment options. ...
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Introduction Despite recommendations, non-surgical treatment modalities in knee and/or hip osteoarthritis (KHOA) are underused. An information campaign was developed targeting patients with early stage KHOA and healthcare professionals (HCPs) to optimise timing of referral to secondary care. This protocol describes the development and design of this information campaign and a randomised controlled trial (RCT) on its effectiveness in impacting healthcare utilisation. Methods and analysis The behaviour change wheel was used as a theoretical framework for the campaign design. After an inventory of the literature, a selection was made of factors influencing healthcare use. Effectiveness will be evaluated with a cluster RCT. The study aims to recruit 300 patients in 24 general practices, randomly allocated to intervention or usual care (ratio 1:1). General practitioners and affiliated HCPs are invited to participate in the trial and recruit patients. Patients are eligible to participate if they are Dutch speaking, aged 50–75 years, registered with KHOA at the general practice, without joint replacement nor having considerable walking impairment. The main end point is the difference in rate of referral to hospital care as reported by patients over a period of 18 months. Secondary parameters include quality of care, beliefs about KHOA treatment modalities, physical activity, self-management behaviour and referral rates to secondary care. Patients receive online questionnaires at baseline, 6, 12 and 18 months. Online questionnaires are sent to HCPs at baseline and after 12 months to assess (changes in) beliefs about KHOA treatment modalities. Ethics and dissemination All methods are carried out in accordance with relevant guidelines and regulations and ethical approval was waived by the Dutch medical research ethical committee of Arnhem-Nijmegen (file number 2020-7246). Trial results will be communicated to participants and patient representatives via news letters, the public via the Sint Maartenskliniek website and journals of patient organisations and HCPs via congresses and international scientific journals. Trial registration number NL9140.
... Hypothetical example digital tool -Clinician dashboardA limited and marginal health literacy reading would recommend clinicians focus on providing repeated oral instructions and visual aids to overcome health literacy difficulties. Clinicians would be provided with examples of and advised to use simple language, avoiding complex terminology, and incorporating illustrations, diagrams and videos to explain medical concepts and instructions26,27 . ...
... Compared to unidirectional (one-way) outreach, interactive communications are preferred because they allow the audience to ask questions and receive feedback, building trust with the communicator (Steelman & McCaffrey, 2015;Novak et al., 2022). Houts et al. (2006) and Harrison (2002) found visual messages, compared to text-based messages, are more convincing and motivating. Bialik (2018) found 14% of adults admitted to changing their opinions on an issue after viewing social media content, and Widyastuti (2021) asserted behavior can be affected through the effective use of social media. ...
... [15][16][17][18][19] Among the various factors reported to influence parents' and, more generally, infant caretakers' behaviors, 20 images act via the influence mechanisms of authority, social proof, and unity. [21][22][23] Images are well established as a modality better remembered than words, a phenomenon known as the "picture-superiority effect". [24][25][26][27] The potential power of images to affect human health behavior led to their use in campaigns to prevent smoking, 28-31 alcohol consumption, 32 sun exposure, 33 and obesity. ...
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Importance: Rates of sudden unexpected death in infancy (SUDI) remain high in several high-income countries. Several studies reported rates of pictures of sleeping infants or infant sleeping environments that were highly inconsistent with safe infant sleep recommendations (SISRs) to prevent SUDI. Objective: To provide robust and synthetized evidence to decision-makers involved in corrective actions, we systematically assessed the proportion of pictures that were inconsistent with SISRs in the visual exposome of infant caretakers. Data Sources: In November 2023, we searched PubMed, Web of Science, and Google Scholar. Study Selection: Eligible studies included were those reporting the quantitative evaluation of the inconsistency between one or several SISRs and pictures depicting sleeping infants or a sleeping environment intended for an infant in physical and digital public spaces. Data Extraction and Synthesis: Data were extracted independently by 2 authors. The risk of bias of included studies was assessed with a customized version of Hoy's tool for prevalence studies. A random-effects logistic regression model was used to obtain summary estimates of proportions of pictures. Between-study heterogeneity was estimated with the I2 statistic. Main Outcomes(s) and Measure(s): The proportion of pictures inconsistent with one or several SISRs from the American Academy of Pediatrics. Results: We screened 1,086 articles and included 7 studies conducted between 2008 and 2023 that analyzed pictures found in parenting magazines, online and print newspapers, baby diaper packaging, commercial stock photography websites, and Instagram. The overall risk of bias was deemed low. Among the 5,442 pictures depicting sleeping infants or infant sleep environments, the summary estimates of the proportion of inconsistencies with SISRs were 39% for a non-supine sleeping position, 5% for a soft sleeping surface, 8% for sharing the sleeping surface, 14% for an unsafe crib, 58% for soft objects or loose bedding, 17% for a covered head, and 85% for at least one SISR inconsistency. All summary estimates had significant between-study heterogeneity. Conclusions and Relevance: Infant caretakers' visual exposome is greatly inconsistent with SISRs and could lead to dangerous practices, which should prompt actions from manufacturers, advertisers, newspaper and website editors, social media moderators, and legislators.
... Visuals often serve as emotionally powerful shortcuts, delivering complex cultural signals in ways that resonate more deeply and immediately with audiences, often leading to stronger memory retention and emotional engagement compared to text (Paivio, 1990). This is consistent with the findings from the healthcare field, where images are found to increase attention and interest (King, 2015), aiding individuals with lower health literacy in understanding health information (Houts, Doak, Doak, & Loscalzo, 2006). Similarly, on social media, users gravitate toward photo-sharing services, as pictures often speak louder than words (Lee, Lee, Moon, & Sung, 2015). ...
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Globalization of cultural goods has grown substantively over the past decade. Rooted in the home-country social context, cultural goods are inherently "foreign" when traded in a host country. However, how foreignness is manifested in cultural goods, and how the associated liability and asset of foreignness jointly affect their host-country market performance remain unclear. We address these questions by examining 304 Hollywood movies in China from 2011 to 2018, focusing on semiotic foreignness-the differences in movie synopses and posters between Hollywood and Chinese movies. We utilize Bidirectional Encoder Representations from Transformers (BERT) to analyze synopses and Structural Similarity Index Measure (SSIM) for posters, which allow us to understand how audiences interpret and perceive foreignness in texts and images. The results show an inverted U-shaped relationship between poster foreignness and Hollywood movie box office sales in China, indicating that moderate poster foreignness drives optimal sales. In comparison, box office performance is insensitive to synopsis foreignness. Our study provides valuable insights into the divided views of foreignness and its role in host-country performance. It also addresses the criticism of the poorly specified and operationalized foreignness construct and makes a first attempt to bridge the literature of international business and optimal distinctiveness.
... [8][9][10][11][12][13] In addition, animated videos can simultaneously be entertaining and educational, which helps sustain the viewer's attention. 8,14,15 The combination of animated videos and speech is advantageous when complex health information is communicated to patients with low health literacy. Thus, animated videos can support equality in comprehension between patients with high and low health literacy, respectively. ...
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Objective: This study examined the potential of simple animations with a low level of detail and their impact on patient’s ability to recall information. Also, we examined how the patients’ digital health literacy influenced the association. Methods: Over 900 Danish adults were continuously included in this experimental study, and they were allocated to either an animation with a low or high level of detail. Participants answered questionnaires about demographics, digital health literacy, and the ability to recall information. The association between level of detail and information recall was examined by OR (95% CI). Results: The results showed no association between the level of detail and information recall. Conclusion: This novel study supports the potential of simple animations, and future research could advantageously investigate animations with more significant differences in level of detail. The results should be cautiously interpreted, as selection and information problems may have caused bias.
... Visuals are a powerful tool for learning. They attract attention, are processed more quickly than text alone, and are easier to recall [4,5]. This may explain why geographic visualizations, or geovisualizations, have become a popular tool for environmental health risk communication. ...
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Purpose of review Informing the public about environmental risks to health is crucial for raising awareness around hazards, and promoting actions that minimize exposures. Geographic visualizations—geovisualizations—have become an increasingly common way to disseminate web-based information about environmental hazards, displaying spatial variations in exposures and health outcomes using a map. Unfortunately, ineffective geovisualizations can result in inaccurate inferences about a hazard, leading to misguided actions or policies. In this narrative review, we discuss key considerations for the use of geovisualizations to promote environmental health literacy. Recent findings Many conventional geovisualizations used for hazard education and risk communication fail to consider how people process visual information. Design choices that prompt viewers to think and feel, leveraging processes such as individual attention, memory, and emotion, could promote improved comprehension and decision making around environmental health risks using geovisualizations. Based on the studies reviewed, we recommend six strategies for designing effective, evidence-based geovisualizations, synthesizing evidence from the cognitive sciences, cartography, and environmental health. These strategies include: Displaying only key data, tailoring and testing geovisualizations with the desired audience, using salient cues, leveraging emotion, aiding pattern recognition, and limiting visual distractions. Summary Geovisualizations offer a promising avenue for advancing public awareness and fostering proactive measures in addressing complex environmental health challenges. This review highlights how incorporating evidence-based design principles into geovisualizations could promote environmental health literacy. More experimental research evaluating geovisualizations, using interdisciplinary approaches, is needed.
... By enabling readers to recreate the authors' analyses step-by-step, papers with executable code promote a more thorough understanding of the published code and can serve as an educational tool. Research has repeatedly shown that the integration of images, videos, and other multimedia information into lessons improves engagement and learning outcomes across a range of scientific literacy levels [78]- [80]. Thus, multimedia publications catalyze education of the next scientific generation. ...
Article
Peer-reviewed scientific journals have been used in formal research communication for decades, but the quality, accessibility, timeliness, clarity, and fairness of articles resulting from the currently dominant publishing model have been questioned. Many novel online publishing strategies have emerged to address gaps in the traditional publishing model. Strategies that reduce or eliminate pre-publication peer review, such as preprints, reduce the cost and time required to publish, thus enhancing accessibility and accelerating science. Other modalities such as multimedia journals provide access to and credit for new types of academic contributions, as well as findings that never result in traditional publications. While scientific grant-funding agencies have begun to embrace preprints and data repositories, most of these organizations have not yet addressed other innovative publishing modalities. Funding for publishing infrastructure development, support for preprints, and changes to grant evaluation guidelines targeted towards rewarding nontraditional publishing could facilitate more widespread adoption of a variety of publishing strategies.
... However, these algorithms may struggle with complex medical concepts or nuanced language, leading to inaccuracies or misinterpretations (Shortliffe & Sepulveda, 2018). Traditional PILs, while static and less interactive, benefit from human expertise and validation, ensuring reliability and accuracy (Houts et al., 2006). Additionally, the study's focus on a specific medical context, namely local anesthesia in eye surgery, may influence the performance of AI chatbots and traditional PILs. ...
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Background and Aim Eye surgeries often evoke strong negative emotions in patients, including fear and anxiety. Patient education material plays a crucial role in informing and empowering individuals. Traditional sources of medical information may not effectively address individual patient concerns or cater to varying levels of understanding. This study aims to conduct a comparative analysis of the accuracy, completeness, readability, tone, and understandability of patient education material generated by AI chatbots versus traditional Patient Information Leaflets (PILs), focusing on local anesthesia in eye surgery. Methods Expert reviewers evaluated responses generated by AI chatbots (ChatGPT and Google Gemini) and a traditional PIL (Royal College of Anaesthetists’ PIL) based on accuracy, completeness, readability, sentiment, and understandability. Statistical analyses, including ANOVA and Tukey HSD tests, were conducted to compare the performance of the sources. Results Readability analysis showed variations in complexity among the sources, with AI chatbots offering simplified language and PILs maintaining better overall readability and accessibility. Sentiment analysis revealed differences in emotional tone, with Google Gemini exhibiting the most positive sentiment. AI chatbots demonstrated superior understandability and actionability, while PILs excelled in completeness. Overall, ChatGPT showed slightly higher accuracy (scores expressed as mean ± standard deviation) (4.71 ± 0.5 vs 4.61 ± 0.62) and completeness (4.55 ± 0.58 vs 4.47 ± 0.58) compared to Google Gemini, but PILs performed best (4.84 ± 0.37 vs 4.88 ± 0.33) in terms of both accuracy and completeness (p-value for completeness <0.05). Conclusion AI chatbots show promise as innovative tools for patient education, complementing traditional PILs. By leveraging the strengths of both AI-driven technologies and human expertise, healthcare providers can enhance patient education and empower individuals to make informed decisions about their health and medical care.
... Communicative visualizations [20] constitute the primary exposure individuals have to visualizations [1]. Beyond the visualization community, infographics are frequently employed to enhance audience engagement [35] and comprehension of information [22], particularly for individuals with low-to-medium graph literacy [19]. We gathered a dataset of 100 visualizations curated by Arunkumar et al. [5] (see a subset in Fig. 2); these visualizations predominantly belong to the category of static infographics, with varying levels of text annotation. ...
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User experience in data visualization is typically assessed through post-viewing self-reports, but these overlook the dynamic cognitive processes during interaction. This study explores the use of mind wandering -- a phenomenon where attention spontaneously shifts from a primary task to internal, task-related thoughts or unrelated distractions -- as a dynamic measure during visualization exploration. Participants reported mind wandering while viewing visualizations from a pre-labeled visualization database and then provided quantitative ratings of trust, engagement, and design quality, along with qualitative descriptions and short-term/long-term recall assessments. Results show that mind wandering negatively affects short-term visualization recall and various post-viewing measures, particularly for visualizations with little text annotation. Further, the type of mind wandering impacts engagement and emotional response. Mind wandering also functions as an intermediate process linking visualization design elements to post-viewing measures, influencing how viewers engage with and interpret visual information over time. Overall, this research underscores the importance of incorporating mind wandering as a dynamic measure in visualization design and evaluation, offering novel avenues for enhancing user engagement and comprehension.
... The question is: What happens if side effects are communicated using pharmaceutical pictograms (e.g., on the medication packaging) instead of with words? Research on pharmaceutical pictograms shows that their application on package inserts supports adherence (e.g., Katz et al., 2006;Mansoor & Dowse, 2003) and improves the comprehensibility of the information to be conveyed (e.g., how to take the medication correctly), which in turn benefits not only illiterate people (Fukuda et al., 2020;Houts et al., 2006;Katz et al., 2006;Knapp et al., 2005;Sletvold et al., 2020). Thus, pictograms might also lead to an improvement in health literacy, for example, in the following respects: "Focus on the ability to make 'well-informed' decisions rather than 'appropriate' ones" (Centers for Disease Control and Prevention, 2023, "What is Health Literacy"). ...
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Introduction and aim: Pictograms can make taking medication safer. However, little is known about how pictograms on a medication package influence the subjective assessment of a medication. Methods: In this online study, 276 participants were presented with a fictitious package that contained 0 to 5 pictograms of possible side effects. Participants had to assess the probability of side effects occurring as well as the benefits and harms of the medication, both before and after consulting the package insert. Results: The number of pictograms (leveling out at 2 pictograms) influenced the assessment of the probability of side effects occurring. In addition, the assessment of this measure served as an anchor for assessing all subsequent measures (e.g., benefit). Although participants adjusted their measures after package insert consultation - these adjustments were insufficient (as expected from a normative probability account). Discussion and conclusion: Pictograms influence medication assessment, and humans can process only a limited number of pictograms.
Article
Erroneous beliefs are difficult to correct. Worse, popular correction strategies, such as the myth-versus-fact article format, may backfire because they subtly reinforce the myths through repetition and further increase the spread and acceptance of misinformation. Here we identify five key criteria people employ as they evaluate the truth of a statement: They assess general acceptance by others, gauge the amount of supporting evidence, determine its compatibility with their beliefs, assess the general coherence of the statement, and judge the credibility of the source of the information. In assessing these five criteria, people can actively seek additional information (an effortful analytic strategy) or attend to the subjective experience of easy mental processing—what psychologists call fluent processing—and simply draw conclusions on the basis of what feels right (a less effortful intuitive strategy). Throughout this truth-evaluation effort, fluent processing can facilitate acceptance of the statement: When thoughts flow smoothly, people nod along. Unfortunately, many correction strategies inadvertently make the false information more easily acceptable by, for example, repeating it or illustrating it with anecdotes and pictures. This, ironically, increases the likelihood that the false information the communicator wanted to debunk will be believed later. A more promising correction strategy is to focus on making the true information as easy to process as possible. We review recent research and offer recommendations for more effective presentation and correction strategies.
Article
Objective This study evaluated the legibility, comprehension, and clinical usability of visual timelines for communicating cancer treatment paths. We examined how these visual aids enhance participants’ and patients’ understanding of their treatment plans. Materials and Methods The study included 2 online surveys and 1 in-person survey with hematology cancer patients. The online surveys involved 306 and 160 participants, respectively, while the clinical evaluation included 30 patients (11 re-surveyed) and 24 medical doctors. Participants were assessed on their ability to understand treatment paths provided with audio information alone or with visual aids. The study also evaluated the comprehensibility of key treatment terms and the ability of patients to recall their cancer treatment paths. Results Visual representations effectively communicated treatment terms, with 7 out of 8 terms achieving over 85% transparency as pictograms, compared to 5 out of 8 for comics and 4 out of 8 for photos. Visual treatment timelines improved the proportion of correct responses, increased confidence, and were rated higher in information quality than audio-only information. In the clinical evaluation, patients showed good comprehension (mean proportion correct: 0.82) and recall (mean proportion correct: 0.71 after several weeks), and both patients and physicians found the visual aids helpful. Discussion We discuss that visual timelines enhance patient comprehension and confidence in cancer communication. We also discuss limitations of the online surveys and clinical evaluation. The importance of accessible visual aids in patient consultations is emphasized, with potential benefits for diverse patient populations. Conclusion Visual aids in the form of treatment timelines improve the legibility and comprehension of cancer treatment paths. Both patients and physicians support integrating these tools into cancer treatment communication.
Chapter
The lack of diversity and inclusion continues in vaccine clinical trials. Despite African Americans being unknowingly and unethically used in the development of lifesaving vaccines, there remains a widespread underrepresentation of Black people in vaccine research. In addition, the history of medical racism has created a tumultuous environment for Black patients, where the disproportionate spread of illnesses associated with COVID-19 continues to reiterate that healthcare continues to be a segregated privilege that is tightly linked to institutional racism. The Centers for Disease Control and Prevention published its COVID-19 Communication Toolkit for Community-Based Organizations in 2020 to help organizations communicate information about the COVID-19 vaccine while addressing community concerns. Utilizing Critical Race Theory and the PEN-3 Cultural Model (PEN-3), this study found that the resources in the toolkit primarily used community-based framing to increase vaccine uptake and used diverse people in its visual communication and marketing resources. However, the toolkit failed to specifically address the nonexistence of African Americans in clinical trial research, the history of medical racism or provide educational information about COVID-19.
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Stunting adalah masalah kesehatan masyarakat yang signifikan, terutama di Desa Fafinesu B, Kecamatan Insana Fafinesu, yang memiliki angka kejadian stunting yang tinggi. Tujuan dari kegiatan pengabdian ini adalah untuk memberikan pemahaman yang lebih baik kepada perangkat desa dan kader posyandu mengenai pentingnya gizi seimbang dan pencegahan stunting melalui pelatihan pembuatan infografis. Metode yang digunakan meliputi presentasi, demonstrasi, dan praktik pembuatan infografis menggunakan Canva, di mana peserta dibagi menjadi kelompok untuk membuat infografis yang kemudian disosialisasikan kepada masyarakat. Hasil survei menunjukkan bahwa pelatihan ini berhasil meningkatkan pengetahuan dan kemampuan peserta dalam membuat dan menggunakan infografis, dengan mayoritas peserta menilai materi pelatihan sangat bermanfaat dan mudah dipahami. Infografis yang dihasilkan diharapkan dapat berperan penting dalam meningkatkan kesadaran masyarakat tentang pencegahan stunting, sehingga membantu menurunkan angka kejadian stunting di desa tersebut.
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Memori merupakan fungsi kognisi yang memiliki hubungan erat dengan kesehatan manusia. Penurunan kemampuan mengingat dapat memengaruhi perilaku individu dalam kehidupan sehari-hari. Penelitian ini bertujuan untuk mengetahui bagaimana pengaruh warna terhadap kemampuan memori jangka pendek mahasiswa Fakultas Psikologi Universitas Negeri Makassar. Penelitian ini menggunakan 16 partisipan dengan kriteria mahasiswa yang tidak mengalami buta warna, baik buta warna parsial maupun total. Penelitian ini menggunakan metode penelitian eksperimen-kuasi dengan dua kelompok yaitu kelompok kontrol dan eksperimen. Penelitian ini menunjukkan bahwa terdapat pengaruh persepsi warna terhadap daya ingat memori jangka pendek. Melalui penelitian ini, diharapkan dapat menjadi dasar dalam melakukan penerapan praktis persepsi warna dalam meningkatkan memori jangka pendek di berbagai aspek layanan kesehatan.
Chapter
The availability of health information in graphic format is quite common across different health issues. Graphic medium poses several advantages, such as being easy to understand, individuals can read and comprehend at their pace, and individuals can mark and review it for future reference. On the other hand, healthcare professionals use graphic health information material to complement verbal discourse. Several rural health missions in India and other organizations use this medium to create awareness on health issues, government-supported schemes, policies, and health guidelines. However, many studies on health communication through graphic mediums raised concerns about the required reading level and suitability of these materials. We reviewed ten maternal healthcare information materials to assess their quality in terms of readability and suitability for the targeted user group. Two assessment tests, Simple Measure of Gobbledygook (SMOG) and Suitability Assessment of Materials (SAM), were performed with the help of community health workers. The assessment scores categorized the health materials under inadequate, adequate, and superior qualities. The evaluation results showed that the majority of the materials were framed at higher reading grades and had inadequate suitability qualities. Commonly observed readability issues were medical jargon, long sentences, blurry text, etc. Commonly observed suitability issues were unclear graphics/illustrations, no caption for images, inconsistent layout, pixelated graphics, inappropriate font sizes, etc. The evaluation result points to a lack of design approach toward framing/developing the healthcare materials. The discussion section touches on key points for consideration to improve the readability and suitability appropriateness. The study concludes with future research objectives to design and develop healthcare information materials for the target user group.KeywordsHealthcare informationPrinted informationReadability factorSuitability factorMaternal health awareness
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Participatory design is an increasingly common informatics method to engage intended audiences in the development of health-related resources. Participatory design is particularly helpful for developing information visualizations that aim to improve health outcomes by means of improved comprehension, communication or engagement, and subsequent behavior changes. Existing literature on participatory design lacks the practical details that influence the success of the method and does not address emergent issues, such as strategies to enhance internet-based data collection. In this tutorial, our objective is to provide practical guidance on how to prepare for, conduct, and analyze participatory design sessions for information visualization. The primary audience for this tutorial is research teams, but this guide is relevant for organizations and other health professionals looking to design visualizations for their patient populations, as they can use this guide as a procedural manual. This start-to-finish guide provides information on how to prepare for design sessions by setting objectives and applying theoretical foundations, planning design sessions to match project goals, conducting design sessions in different formats with varying populations, and carrying out effective analysis. We also address how the methods in this guide can be implemented in the context of resource constraints. This tutorial contains a glossary of relevant terms, pros and cons of variations in the type of design session, an informed consent template, a preparation checklist, a sample design session guide and selection of useful design session prompts, and examples of how surveys can supplement the design process.
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Introduction: Personalised Asthma Action Plans (AAPs) are a cornerstone of paediatric asthma management. We aimed to assess parental knowledge and perceptions of the use of AAPs in managing their child's asthma. Methods: In 2023 we conducted a cross-sectional survey to assess knowledge and perceptions of AAPs in parents/caregivers of children aged 0-17 years with asthma who had an AAP and attended respiratory clinics at Sydney Children's Hospital, Randwick. The questionnaire included parental perceptions on the utility of AAPs, parental asthma management self-efficacy (PAMSE), and an adapted version of the Asthma Action Plan Knowledge Interview tool (AAPKI). Descriptive statistics and regression analyses were used to assess associations between AAPKI, PAMSE and other outcomes. Results: Seventy-one parents completed the survey. Mean PAMSE score was 4.2/5 (SD 0.5). Median AAPKI score was 70.2% out of 100% (IQR 20.4%). Most parents (80.0%, n = 56) were satisfied/very satisfied with using AAPs to manage their child's asthma. Most agreed/strongly agreed that AAPs were helpful in knowing when to seek medical attention for their child's asthma (81.7%, n = 58), helped their understanding of asthma severity (81.7%, n = 58), and increased their confidence in asthma management (76.0%, n = 54). Over half of parents (55.7%, n = 39) would prefer AAPs digitally and majority (78.6%, n = 55) would like colour-coded AAPs. Conclusion: High levels of AAP knowledge and self-efficacy scores were demonstrated. Most parents expressed understanding of the benefits of AAPs. Our findings suggest parents of children with asthma prefer AAPs in colour and in digital version which may help guide standardisation of AAPs across Australia.
Article
Purpose This paper presents a 10-year systematic review of research on the visual framing of crises to identify the priorities, theories applied and trends in the scholarship of visual framing during crises. The gaps are analyzed to provide evidence-based recommendations for advancing future research. Design/methodology/approach A total of 269 articles published in 156 peer-reviewed communication journals between January 2014 to December 2023 were reviewed. Data were analyzed using open and axial qualitative coding. A codebook was developed for the quantitative coding and data were analyzed in SPSS descriptive statistics and chi-square tests to answer the research questions. Findings The proportion of visual framing of crises has remained the same in the last 10 years – there is significantly more research on the visual framing of non-crises. Overall, research on the visual framing of crises is largely exploratory/descriptive and could benefit from a research agenda that is more theory driven. Additionally, there is a skewed focus for research on North America compared to other regions, and for political communication and climate compared to other themes. Environmental sciences and engineering are the most widely investigated journal fields, while disaster is the most common typology studied when looking at the visual framing of crises. Research limitations/implications The systematic literature review has some limitations – most particularly that the sample was drawn from a single publisher, which may not be exhaustive enough to represent the full population of articles in the field of visual communication. However, it is a systematic review of the publications that are officially aligned with three of the major communication organizations – the International Communication Association, National Communication Association and World Communication Association. However, future research considering the inclusion of an additional publishers, like Emerald, would further enrich scholarship in visual framing during crises. Second, manual coding of the articles could present potential differences in analysis and interpretation by other researchers. Despite the limitations, the study also provides some important insights into the present and future of the visual framing of crises. Practical implications Addressing gaps in the internationalization of visual crisis communication would expand studies for visual framing among underrepresented communities such as populations with low reading literacy, gender minorities and displaced communities and inform visual framing strategies for government and relevant institutions as primary information disseminators during crises. Social implications Addressing the gaps identified in this systematic literature review on the visual framing of crises is important for extending theory in this relatively nascent field and guiding crisis visual framing strategies to mitigate uncertainty and panic, threats to stakeholder relationships, social vulnerabilities and the visual framing of stakeholder-centric crisis responses. Originality/value Based on available literature, this is the first systematic literature review investigating the use of all types of visuals used during all crisis typologies, reflecting the ubiquity of crises and the increased focus on the use of visuals in crisis communication in the last decade.
Article
Background Digital health tools have demonstrated promise in the treatment and self-management of chronic diseases while also serving as an important means for reducing the workload of health care professionals (HCPs) and enhancing the quality of care. However, these tools often merely undergo large-scale testing or enter the market without undergoing rigorous user experience analysis in the early stages of their development, leading to frequent instances of low use or failure. Objective This study aims to assess the usability of and satisfaction with a mobile app designed for the clinical monitoring of patients with chronic obstructive pulmonary disease undergoing pulmonary rehabilitation at home. Methods This study used a mixed methods approach involving two key stakeholders—patients with chronic obstructive pulmonary disease and HCPs—across three phases: (1) mobile app mock-up design, (2) usability testing, and (3) satisfaction evaluation. Using convenience sampling, participants were grouped as HCPs (n=12) and patients (n=18). Each received a tablet with mock-ups for usability testing through interviews, with audio recordings transcribed and analyzed anonymously in NVivo12.0, focusing on mock-up features and usability insights. Task difficulty was rated from 1 (very easy) to 5 (very difficult), with noncompletion deemed a critical error. Usability satisfaction was measured on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). Results The research indicated a notable difference in app usability perceptions: 66% (8/12) of HCPs found tasks “very easy,” compared to only 22% (4/18) of patients. Despite this, no participant made critical errors or withdrew, and satisfaction was high. HCPs completed tasks in about 20 minutes, while patients took 30. Older adults faced challenges with touch screens and scroll menus, suggesting the need for intuitive design aids like auditory support and visual health progress indicators, such as graphs. HCPs noted potential data delays affecting service, while non–native-speaking caregivers faced interpretation challenges. A secure pairing system for privacy in teleconsultations proved difficult for older users; a simpler icon-based system is recommended. This study highlights the need to consider stakeholder abilities in medical app design to enhance function implementation. Conclusions Most HCPs (11/12, 91%) found the app intuitive, though they recommended adding icons to show patient progress to support clinical decisions. In contrast, 62% (11/18) of patients struggled with tablet navigation, especially with connectivity features. To ensure equitable access, the design should accommodate older users with diverse abilities. Despite challenges, both groups reported high satisfaction, with patients expressing a willingness to learn and recommending the app. These positive usability evaluations suggest that, with design improvements, such apps could see increased use in home-based care.
Article
User experience in data visualization is typically assessed through post-viewing self-reports, but these overlook the dynamic cognitive processes during interaction. This study explores the use of mind wandering– a phenomenon where attention spontaneously shifts from a primary task to internal, task-related thoughts or unrelated distractions– as a dynamic measure during visualization exploration. Participants reported mind wandering while viewing visualizations from a pre-labeled visualization database and then provided quantitative ratings of trust, engagement, and design quality, along with qualitative descriptions and short-term/long-term recall assessments. Results show that mind wandering negatively affects short-term visualization recall and various post-viewing measures, particularly for visualizations with little text annotation. Further, the type of mind wandering impacts engagement and emotional response. Mind wandering also functions as an intermediate process linking visualization design elements to post-viewing measures, influencing how viewers engage with and interpret visual information over time. Overall, this research underscores the importance of incorporating mind wandering as a dynamic measure in visualization design and evaluation, offering novel avenues for enhancing user engagement and comprehension.
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The objective of this study is to evaluate users’ perceptions and preferences on the design features of the COVID-19 prevention promotion icon from the perspective of users’ aesthetic and perceptual needs. In this study, 120 officially published icons from 24 countries and regions were collected from online platforms for ranking tests, and then the top-ranked icons were subjectively rated by the semantic differential method. By evaluating the quality of users’ perceptions of multiple semantic dimensions of icons, we extracted the perceptual semantic words that users valued as the main icon design features. Spearmen correlations were applied to derive possible correlations between user rankings and semantic scales, and a Friedman test was also conducted to determine the true differences in user perceptions and preferences for different styles of icons. Factor analysis was conducted to extract six perceptual words that influence the design features of the COVID-19 prevention promotion icon. The methodology adopted in this study facilitated the screening of design features related to icon effectiveness, and the findings show that “Interesting,” “Simple,” “Familiar, “Recognizable,” “Concrete,” and “Close(semantic distance)” are the key features that influence users’ perception and preference of COVID-19 icon design. The results of this study can be used as the basis for designing and improving publicity icons for preventive measures in COVID-19, and the methods adopted in this study can be applied to evaluate other types of icon design.
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Introduction With digital and social media advances, animated health communications (health animations) are highly prevalent globally, yet the evidence base underpinning them remains unclear and limited. While individual studies have attempted to explore the effectiveness, acceptability and usability of specific features of health animations, there is substantial heterogeneity in study design, comparators and the animation design and content. Consequently, there is a need to synthesise evidence of health animations using an approach that recognises this contextual complexity, which may affect their impact. Methods and analysis This project aims to understand why, how, for whom, to what extent and in which contexts health animations are expected to promote preventive health behaviours. We will conduct a realist review following Pawson’s five iterative stages to (1) define the review scope and locate existing theories; (2) search for evidence; (3) select and appraise evidence; (4) extract data and (5) synthesise data and refine theory. Engagement with stakeholders involved in developing, testing, implementing or commissioning health communications, including animations, will allow the initial programme theory to be tested and refined. The findings will be reported in accordance with Realist and Meta-narrative Evidence Syntheses: Evolving Standards. Ethics and dissemination Ethical approval for the public stakeholder work was provided by the Northumbria University Research Ethics Committee. We will disseminate the findings widely through outputs tailored to target specific professional, public and patient audiences. Dissemination will occur through stakeholder engagement as part of the research, a peer-reviewed publication and conference presentations. PROSPERO registration number CRD42023447127.
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Background Parents and survivors of retinoblastoma often hold misconceptions about the disease and desire more extensive and detailed information about its genetic nature. The aim of this study was to co‐develop and evaluate a genetic education booklet for retinoblastoma. Methods A human‐centered design approach was employed, in which the study team consulted with clinician and patient knowledge user groups to design, produce, and refine an educational booklet. Over three phases of consultation, the study team met with each knowledge user group to review booklet prototypes and collect feedback for its further refinement. A preliminary evaluation using quantitative and qualitative methods was completed with six mothers of children with retinoblastoma. Results The iterative, phased design process produced an educational booklet rich in images and stories, with complex genetic topics described in simplified terms. The preliminary evaluation showed an average improvement in knowledge between pre‐ and post‐test questionnaire of 10%. Participants were satisfied with content and comprehensiveness of the information included in the booklet. Conclusion A novel educational tool for families affected by retinoblastoma was developed through collaboration with health care and patient knowledge users. Preliminary evaluation results indicate it is feasible to implement and study the booklet in a prospective, pragmatic trial to evaluate its efficacy.
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Research conducted primarily during the 1970s and 1980s supported the assertion that carefully constructed text illustrations generally enhance learners' performance on a variety of text-dependent cognitive outcomes. Research conducted throughout the 1990s still strongly supports that assertion. The more recent research has extended pictures-in-text conclusions to alternative media and technological formats and has begun to explore more systematically the “whys,” “whens,” and “for whoms” of picture facilitation, in addition to the “whethers” and “how muchs.” Consideration is given here to both more and less conventional types of textbook illustration, with several “tenets for teachers” provided in relation to each type.
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We examined whether timeline icons improved older and younger adults' comprehension of medication information. In Experiment 1, comprehension of instructions with the icon (icon/text format) and without the icon (text-only format) was assessed by questions about information that was (a) implicit in the text but depicted explicitly by the icon (total dose in a 24 hour period), (b) stated and depicted in the icon/text condition (medication dose and times), and (c) stated but not depicted by the icon (e.g., side effects). In a separate task, participants also recalled medication instructions (with or without the icon) after a study period. We found that questions about dose and time information were answered more quickly and accurately when the icon was present in the instructions. Notably, icon benefits were greater for information that was implicit rather than stated in the text. This finding suggests that icons can improve older and younger adults' comprehension by reducing the need to draw some inferences. The icon also reduced effective study time (study time per item recalled). In Experiment 2, icon benefits did not occur for a less integrated version of the timeline icon that, like the text, required participants to integrate dose and time information in order to identify the total daily dose. The integrated version of the icon again improved comprehension, as in Experiment 1, as well as drawing inferences from memory. These findings show that integrated timeline icons improved comprehension primarily by aiding the integration of dose and time information. These findings are discussed in terms of a situation model approach to comprehension.
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Elderly patients may have limited ability to read and comprehend medical information pertinent to their health. To determine the prevalence of low functional health literacy among community-dwelling Medicare enrollees in a national managed care organization. Cross-sectional survey. Four Prudential HealthCare plans (Cleveland, Ohio; Houston, Tex; south Florida; Tampa, Fla). A total of 3260 new Medicare enrollees aged 65 years or older were interviewed in person between June and December 1997 (853 in Cleveland, 498 in Houston, 975 in south Florida, 934 in Tampa); 2956 spoke English and 304 spoke Spanish as their native language. MAIN OUTCOME MEASURE; Functional health literacy as measured by the Short Test of Functional Health Literacy in Adults. Overall, 33.9% of English-speaking and 53.9% of Spanish-speaking respondents had inadequate or marginal health literacy. The prevalence of inadequate or marginal functional health literacy among English speakers ranged from 26.8% to 44.0%. In multivariate analysis, study location, race/language, age, years of school completed, occupation, and cognitive impairment were significantly associated with inadequate or marginal literacy. Reading ability declined dramatically with age, even after adjusting for years of school completed and cognitive impairment. The adjusted odds ratio for having inadequate or marginal health literacy was 8.62 (95% confidence interval, 5.55-13.38) for enrollees aged 85 years or older compared with individuals aged 65 to 69 years. Elderly managed care enrollees may not have the literacy skills necessary to function adequately in the health care environment. Low health literacy may impair elderly patients' understanding of health messages and limit their ability to care for their medical problems.
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The first study in this series [Houts PS, Bachrach R, Witmer JT, Tringali CA, Bucher JA, Localio RA. Patient Educ. Couns. 1998;35:83-8] found that recall of spoken medical instructions averaged 14% but that, when pictographs (drawings representing the instructions) accompanied the spoken instructions and were present during recall, 85% of medical instructions were remembered correctly. Those findings suggested that spoken instructions plus pictographs may be a way to give people with low literacy skills access to medical information that is normally available only in written form. However, there were three important limitations to that study: (1) the subjects were literate and perhaps literate people remember pictograph meanings better than people with low literacy skills; (2) only short term recall was tested and, for medical information to be useful clinically, it must be remembered for significant periods of time and (3) a maximum of 50 instructions were shown in pictographs, whereas managing complex illnesses may require remembering several hundred instructions. This study addresses those limitations by investigating 4-week recall of 236 medical instructions accompanied by pictographs by people with low literacy skills. Subjects were 21 adult clients of an inner city job training program who had less than fifth grade reading skills. Results showed 85% mean correct recall of pictograph meanings immediately after training (range from 63 to 99%) and 71% after 4 weeks (range from 33 to 94%). These results indicate that people with low literacy skills can, with the help of pictographs, recall large amounts of medical information for significant periods of time. The impact of pictographs on symptom management and patient quality of life remains to be studied.
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One hundred and ninety-six patients over the age of 65 years suffering from joint pain were randomised to receive one of three patient information leaflets describing a hypothetical pain medication, a standard textual patient information leaflet (PIL) given out by a pharmaceutical chain, and two alternate-forms depicting information with icons and graphs. The results showed that patients randomised to the traditional PIL were less likely to consider taking the hypothetical medication.
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Communication is a major problem in the management of patients. Miscommunication occurs frequently in populations with low reading skills, illiteracy does not completely account for the observed low rates of recall of communicated information. Transmission of the message also plays an important role. Successful strategies to improve communication with patients include the use of videotapes, videotape modeling or cartoon illustrations. Do these products communicate effectively because they overcome illiteracy or because they also transmit a very clear message? Can good transmission of messages overcome illiteracy? In this study, we compared the effectiveness of a printed message about polio vaccinations with the same message converted into a production of animated cartoons using marketing and advertising techniques. The production that resulted from using this strategy showed that in the setting of this study, a well-designed animated cartoon is more effective in delivering a message than the same information provided in written instructional materials.
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To design, develop, and evaluate a simple, understandable medicine label and patient information leaflet (PIL) for nystatin suspension, and to assess the effect of incorporating pictograms on understanding in low-literate participants. Patient information materials were designed and pretested in a pilot study (n = 20), and were subjected to the Fry's readability test. The final evaluation was conducted with 60 low-literate participants who had a maximum of 7 years of formal schooling and for whom English was their second language. Demographic data were collected. Participants were randomly allocated to a control (text-only information) or experimental (text + pictogram information) group, shown the medicine label and PIL, and asked to read them. A series of questions was asked about the instructions and an understanding level was calculated in each case. A second series of questions assessed patient acceptability of the materials. Differences in understanding were determined by chi(2) tests. Both sets of these simple written materials were generally well understood. However, the presence of pictograms was shown to improve the comprehension of more complex information, resulting in significantly more participants in the experimental group obtaining a score for understanding >80% for both the medicine label and PIL. A clear preference for the materials incorporating pictograms was expressed. The presence of pictograms had a positive effect in the acquisition and comprehension of drug information.
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This collection of papers by William J. McGuire reports research on the phenomenal self, revealing how we selectively perceive ourselves and other complex stimuli in terms of distinctive or atypical features, often noticing what is missing rather than what is there. The content, structure, and processing of thought systems surrounding the self and other complex stimuli are shown to function by balancing logical consistency, realistic coping, and hedonic gratification. Attitude change and social influence processes are described, with particular attention given to the personality correlates of persuasability, how beliefs can be immunized against persuasion, how persuasive communications affect beliefs, and how people can be persuaded by Socratic questioning that does not give them new information but rather directs their attention to information they already have. Also reported are findings on language and thought, psychology and history, and techniques of creative thinking in psychology and other fields.
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This review examines the use of pictograms in health care. Well designed pictograms are simple, clear, graphic symbols able to convey their intended meaning to all patients, including those who are illiterate, elderly or visually impaired. Although some research on the effectiveness of pictograms has not supported the hypothesis that pictograms are beneficial for the acquisition and comprehension of information, most studies investigating health-related applications of pictograms have shown them to be of benefit in the comprehension and recall of instructions on prescription and over-the-counter medicines. However, the success of pictograms as a communication aid in pharmacy depends first on a rigorous design process, followed by well-designed, randomised, controlled trials using an appropriate method of evaluation. The final stage is to investigate the optimal way of using pictograms in practice and to assess their effect on behavioural outcomes, such as compliance. We discuss methodological issues associated with the design process of pictograms, the evaluation of pictograms in practice, reasons for their use in pharmacy and their potential in improving medication compliance. We also report on the positive and negative aspects of various pictograms that have been developed and tested in pharmacy.
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For which readers and texts are different types of Pictures and/or Titles ‘worth a thousand words'? Pictures and Titles are extensively used in reading materials under the assumption that they enhance individuals’ motivation for reading, and that they also facilitate reading. This paper presents findings from studies into the effects of Pictures and/or Titles on the reading and comprehension of continuous printed text.The transfer‐appropriate processing hypothesis encourages the specification of conditions under which Pictures and/or Titles enhance or interfere with children's text‐processing skills. Such studies contribute to an evolving theory of the cognitive conditions required for meaningful learning from materials comprising continuous text, Pictures and Titles.Four groups of researches are summarized. The first considers the effects of Pictures on Reading Comprehension (17 studies). The second summarizes work on effects of Pictures on both Reading Accuracy and Reading Comprehension (three studies). Turning to Titles, their effects on comprehension are presented (five studies). The fourth section summarizes studies into the effects of both Pictures and Titles on Reading Comprehension (four studies). Finally, one study that simultaneously examines the effects of both Pictures and Titles in relation to Reading Accuracy and Reading Comprehension is presented.Three main points emerge from the Picture and Title research reviewed. The first is that Pictures and Titles are not uniformly effective in all prose‐reading situations. The second is that not all types of Pictures and Titles are equally effective for children with differing reading abilities. Both of these points are, in part, a consequence of methodological variations between researches, coupled with their respective limitations. Despite such limitations, an appreciation of such work suggests that teachers and textbook producers could increase slightly the likelihood of Pictures and Titles being effective in facilitating Reading Accuracy and Reading Comprehension for particular groups of readers. The third point raised by this survey is the challenge inherent in the first two. Can Pictures and/or Titles that systematically and differentially affect the accessibility of running text be constructed for children with different reading attainments and learning styles working with text of various genres?
Article
Overall findings of the analysis of published studies reveal small effects of adjunct pictures on reading comprehension. No advantage was found when traditional vs nontraditional text settings were compared. Generally small effects were found for nontraditional text settings at both public school and university levels. On the other hand, a large effect was noted for university-level subjects in traditional text settings. Additionally, line drawings seem to facilitate comprehension more than do shaded drawings or photographs, and color pictures seem to have a greater effect than black and white pictures. Only a slight difference between immediate vs posttests was found. (40 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
It is estimated that 1 out of 5 American adults lacks the literacy skills needed to function effectively in todays society and as patients they present a challenge to health instruction. This book provides teaching strategies to aid in making self-help and self-management a reality for the patient with low literacy skills. The magnitude of the problem is explored and myths about illiteracy are exemplified. Two chapters deal with comprehension of written materials from theory to practical proven testing techniques including the cloze technique and the word-recognition test. Another chapter offers 2 formulas for testing the readability of written materials: the SMOG formula and the Fry index. Once a problem is identified a 4-step teaching strategy gives tips on teaching the low-literacy patient. For those pamphlets and booklets commonly given to patients suggestions for writing and rewriting to simplify the text are given along with examples of comprehension level. The use of audiotapes for teaching is explored in depth for those who learn better by listening. A chapter on the use of visuals stresses simplification to reduce the amount of text reading to emphasize instruction and to motivate and appropriate examples are given. Where written material audiotapes and visuals are drafted and produced according to the guidelines in the book the last chapter is devoted to pretesting to determine whether intended concepts are coming through. It defines the components of pretesting describes procedures discusses possible stages for production and provides examples of results. Although the book is aimed at providing teaching methods for the low-literate patient the suggestions also apply to the learning disabled.
Article
One of us had agreed to participate in the “Mothers' March” (on Birth Defects) of the March of Dimes. The collecting packet arrived without an identification badge, however. Much of the March of Dimes literature bears the picture of a handicapped child, but some does not. The question facing us as we set out to collect for the “Mothers' March” was whether or not to include a picture of a handicapped child on the identifying poster which we would present to potential donors as we made our rounds, door-todoor. A picture is worth a thousand words, they say. But what would be the effect of a thousand words when collecting door-tedoor on behalf of a charity such as the March of Dimes?
Article
People's level of erotophobia influences their acceptance of sexually related situations, including the likelihood of engaging in sexually related health care such as breast self-examinations (BSE). Female college students (n= 61) completed a measure of erotophobia and read a BSE brochure that either did or did not contain instructional photographs showing a woman's breasts. As hypothesized when the brochure contained photographs, women high in erotophobia felt less competent in giving themselves BSE and were less likely to claim that they did things to improve their health. When the brochure contained no photographs, women low in erotophobia thought that the information was easier to understand and that BSE was more important.
Article
This paper reports two studies on comprehension of pharmaceutical texta containing pictorial and written instructions by mothers in rural Kenya. The subjects were asked to read and recall instructions for preparing and administering a solution for the treatment of dehydration due to diarrheal disease in children. A set of pictures describing the preparation procedure, together with written text instructions under two conditions, (a) original, as in the commercial product, and (b) revised, to include familiar terminology and explanations of some procedures, were presented to two groups of Kenyan mothers. The verbal protocols generated were transcribed and analyzed using propositional representation of instructional procedures. The results showed that mothers recalled the procedures for the preparation as in the pictures but not those presented in the written instructions. The written instructions were generally found to be difficult, with the original text being more difficult than the revised text. Any conflicting information between the written and pictorial instructions was resolved by selecting the familiar procedure. The information recalled from the revised text that was recalled was that which supported the procedures in the pictures. The results have implications for writing adequate pharmaceutical texts for users such that little room is left for misinterpretation.
Article
Can illustrations aid learning of text material? These authors review the results of 55 experiments comparing learning from illustrated text with learning from text alone. They go on to look at research in closely related fields (involving, for example, nonrepresentational pictures, graphic organizers, learner-produced drawings) and conclude by offering guidelines for practice.
Article
There is broad acceptance of the philosophic foundations of health education as grounded in the collaborative model of client and professional partnership. In practice, however, this partnership is largely dominated by the professional side. Workers may be particularly sensitive to professional domination as issues associated with health promotion vs. safety and health programs at the workplace are often politicized. This polarization is particularly evident in the area of asbestos-related hazard prevention, reduction, and education. Using asbestos hazards as the unifying theme, we participated in a program to facilitate active participation of workers in the production of their own occupational health education materials through the use of the photonovel. Representatives from some seven building trade locals worked with a staff to produce a twenty-four-page photonovel for their co-workers. A random sample of 500 members of building trades locals received either a copy of the photonovel or a popular NCI asbestos pamphlet with an evaluation questionnaire. Differences between the groups were evident in favor of the photonovel in readability, factual recall, general credibility, and attitudes toward future involvement in health and safety issues.
Article
A sample of 50 consecutive patients with gout was tested by means of a multiple-choice knowledge-testing questionnaire based on the Arthritis and Rheumatism Council's Gout: A Handbook for Patients. Patients were divided into two groups: (a) those tested with an illustrated booklet containing 89 cartoons, and (b) those tested with an unillustrated booklet with text exactly the same as in the illustrated booklet. No significant difference was observed in either the overall test scores between the two groups or between individual question scores. It was concluded that increasing the number of illustrations in the Arthritis and Rheumatism Council's handbook on gout had not significantly increased the value of this material as a communication aid. Certain sources of error have been discussed including the possibility of an 'interest factor' due to the inevitable interest patients have in reading about their own disease, and also the possibility that technical factors to do with page layout and picture/text imbalance might be responsible for failing to show differences between the two groups.
Article
Research suggests that much of the available health education literature requires a level of reading ability that makes it inaccessible to a large proportion of the population in greatest need of health information. The present study tested the value of illustrations and a narrative text style as means of improving the readability of a brochure designed to provide information on cervical cancer and condyloma. Two versions of the brochure were designed, one that had only text presented as simple sentences in bullet-type format (SMOG reading level score of 7.7), and a second version that had somewhat more difficult text formatted in a narrative style (SMOG grade level score of 8.4) together with drawings designed to complement the text. A randomized study design was used to test for comprehension, perceived ease of understanding, and overall rating of the two brochures. Women selected from one private and three public health primary-care clinics were randomly assigned to read one of the two brochures. The brochure with illustrations and narrative text was given a significantly higher overall rating than the one with bullet-type text and no illustrations, while no difference was found in perceived ease of reading. Among poor readers, comprehension was significantly greater for women who read the brochure with illustrations and narrative text, with no difference in comprehension of the two brochures for better readers. The results suggest that the use of aids such as illustrations and text style can make health education literature more accessible to high-risk populations, while remaining interesting enough to appeal to individuals at all levels of reading ability.
Article
This study investigated the reading level estimates of cancer clinical trial consent forms from actively accruing studies at the Medicine Branch and the Clinical Pharmacology Branch of the National Cancer Institute. Forty-four consent forms were analyzed using the SMOG formula. Readability levels ranged from grade 12 to grade 17.5 (mean = 14.3). The conclusion was that these consent forms were written above most subjects' reading levels. The usefulness of consent forms could be improved significantly by using readability formulas, applying rewriting techniques, and being aware of subjects' comprehension levels. This paper suggests a number of strategies that nurses can use to enhance comprehension of the information contained in informed consent documents.
Article
American Cancer Society (ACS) literature commonly used to inform patients about cancer-detection methods, life-style risks, and treatment modalities was examined for readability. Fifty-one booklets obtained from a regional ACS office were evaluated. According to the SMOG formula, the reading level estimates of the booklets ranged from grade 5.8-15.6 (SD = 2.2), with a mean reading level of grade 11.9. The sampled cancer materials may be too difficult for many Americans to read and understand since most of the booklets (55%) were written for individuals with grade 12 or higher reading skills. Only one booklet was written at less than a grade six reading level. Booklets produced since 1985 were written at significantly lower reading levels (p less than 0.05) than those published in earlier years. The nurse's role in cancer education encompasses awareness of patients' diverse reading skills and formulation of a systematic method to develop materials that meet the needs of low-literacy groups.
Article
We conducted a study to determine the effects of presenting prescription information in a pictorial compared to a verbal format on comprehension and memory in young and old adults. Both comprehension and memory for drug information were studied as a function of age and presentation method. Participants received prescription instructions on actual medicine bottles in one of two formats: verbal instructions only, or verbal instructions mixed with pictorial representations. Results indicated that (a) younger adults' memory for prescription information was facilitated by the mixed instructions, but that mixed instructions appeared to hamper older adults' memory for prescription information; (b) younger adults recalled more information overall relative to older adults across both presentation conditions; and (c) older adults were less able to comprehend prescription information relative to younger adults. Results suggest that well-organized verbal prescription labels are more facilitative for the elderly and that additional efforts must be undertaken to improve the clarity of labeling on prescription drugs.
Article
Effective illustrations can greatly enhance patient education materials, yet many illustrations do not aid instruction as much as they could. By following the above recommendations, patient education materials developers and illustrators can together accomplish their objectives.
Article
This article reports the results of an analysis of the readability levels and content of 38 print cholesterol education materials available from government, health agency, professional association, university and industry sources. Each item was characterized according to the primary intended audience (general public, public and screening participants, or those identified with elevated cholesterol and patients in treatment), size, length and appearance. Readability analysis was done using the SMOG and Fog Grading formulas and content analysis examined the presence of messages in each of nine key areas. The readability assessment revealed that the average reading grade level was close to Grade 11, which is too difficult for many adults. Content analysis suggested a need to better address other heart disease risk factors, portion size and the use of brand name food recommendations. Further practice and research needs are identified.
Article
This paper describes the methods used to develop and evaluate diabetes education material for American Indians and Alaska Natives living in Washington, Oregon, and Idaho. Reading skills of individuals and readability of a sample of existing diabetic education material were measured. Using the Wide Range Achievement Test to measure reading skills, the authors found that 66% of the sample read at a 5th "grade" or higher level. Readability of a sample of available diabetic education material was found to be, on average, at the 10th "grade" level. Diabetes education booklets targeted to a 5th to 7th "grade" level were developed and assessed for acceptability and comprehension. Final evaluation, using the close procedure, showed that 62% of the target audience understood the messages in the booklets. A comprehensive assessment process was found to be useful in developing effective diabetes education material for Indian communities.
Article
Patients (n = 404) with osteoarthrosis and control subjects (n = 233) were studied to examine the communicational value of five styles of illustration (cartoon (C), matchstick (M), representational (R), symbolic (S), photographic (P) and two levels of text ('easy', 'hard'), presented as educational booklets about osteoarthrosis. Booklet comprehension was tested with a multiple choice questionnaire (MCQ) scored by two raw score and two, more sensitive, weight-of-evidence methods. Further studies assessed perception of image detail, tone, and colour by ranking, rating, latency, and questionnaire methods. A subgroup was tested psychometrically. The main findings were: pictures in booklets enhance communication; perception of pictorial style depends on its vehicle of presentation, cartoons being most effective in booklets, photographs overall; simplifying text does not significantly enhance communication; certain picture-text 'interactions' appear to increase comprehension (e.g. 'hard' text with 'easy' pictures); several 'endogenous' factors are associated with increased comprehension: 'psychological' (e.g., intelligence, memory, reading skill); 'demographic' (e.g., the young, males, higher social grades, higher educational levels); 'disease' (e.g., longer disease duration, previous information about the disease).
Article
One recurrent theme in the literature on aging and memory is that the decline of memory for nonverbal information is steeper than for verbal information. This research compares verbal and visual encoding using the picture superiority effect, the finding that pictures are remembered better than words. In the first experiment, an interaction was found between age and type of material; younger subjects recalled more pictures than words while older subjects did not. However, the overall effect was small and two further experiments were conducted. In both of these experiments, the picture superiority effect was found in both age groups with no interaction. In addition, performing a semantic orienting task had no effect on recall. The finding of a picture superiority effect in older subjects indicates that nonverbal codes can be effectively used by subjects in all age groups to facilitate memory performance.
Article
The literature on communication, compliance, and patient satisfaction is selectively reviewed. As in earlier reviews, it is concluded that dissatisfaction with communication remains widespread, as does lack of compliance with medical advice. Related factors include poor transmission of information from patient to doctor, low understandability of communications addressed to the patient, and low levels of recall of information by patients. There does not appear to be any evidence that provision of additional information leads to adverse reactions by patients. Theoretical approaches to communication and compliance are described, and it is concluded that these should be used to direct future research.
Article
A consent to treatment form provides required information that a patient may use to give intelligent, informed consent to proposed treatment. This study applied two standard techniques to assess the degree to which 60 informed consent forms from five national cancer clinical trial groups were readable and understandable by patients. The forms were found slightly less difficult to comprehend than medical journals but substantially more difficult than comparable materials from the popular press. Three of four passages describing treatment methods, procedures, discomforts, and risks required a college level or greater reading ability to comprehend. Informed consent documents may not be understood by a substantial portion of patients who sign them. The very regulations designed to ensure a patient's informed cooperation with treatment may inadvertently lead to forms that are so complex as to make informed cooperation virtually impossible.
Article
To determine whether the addition of illustrations to discharge instructions improves patient comprehension. Randomized, blinded, prospective study. A blinded investigator asked a series of questions designed to test the participant's comprehension of the discharge instructions. There were 10 possible correct responses. Emergency department of a rural Level I trauma center. Convenience sample of 101 patients discharged with the diagnosis of laceration. Patients were randomly assigned to receive discharge instructions with (n = 54) or without (n = 47) illustrations. The median number of correct responses was five. Patients with illustrations were 1.5 times more likely to choose five or more correct responses than those without illustrations (65% versus 43%; P = .033). The effect of illustrations varied by demographic group. Among nonwhites (n = 51), patients with illustrations were more than twice as likely to choose five or more correct responses (P = .032). Among patients with no more than a high school education (n = 71), patients with illustrations were 1.8 times more likely to choose five or more correct responses (P = .038). Among women (n = 48), patients with illustrations were 1.7 times more likely to chose five or more correct responses (P = .006). The addition of illustrations to discharge instructions for patients who have sustained lacerations improves patient comprehension. There is a large effect among patients who are nonwhite, female, or have no more than a high school education.
Article
Medical information pamphlets often are written using language that requires a reading level higher than parents of many pediatric patients have achieved. Anecdotal reports suggest that many parents may not readily understand the federally mandated Public Health Service vaccine information pamphlets prepared by the Centers for Disease Control and Prevention (CDC) in 1991. The level at which the pamphlets need to be written for low-reading-level parents is undetermined, as is whether parents reading at higher levels will accept low-reading-level materials. To determine whether a simple pamphlet prepared at a low reading level using qualitative and adult education techniques would be preferable to the available CDC polio vaccine information pamphlet, we conducted an integrated qualitative-quantitative study. We compared the parent reading time and comprehension of a simplified pamphlet (Louisiana State University, LSU) comprising 4 pages, 322 words, 7 instructional graphics, and a text requiring a 6th grade reading ability with the equivalent 1991 CDC vaccine information pamphlet comprising 16 pages, 18,177 words, no graphics, and a text requiring a 10th grade reading level. We measured the reading ability of 522 parents of pediatric patients from northwest Louisiana seen at public clinics (81%) and in a private office (19%). Of the entire group, 39% were white, 60% African-American, and 1% Hispanic; the mean age was 29 years; the mean highest grade completed was 12th grade 3 months; and the reading level was less than 9th grade in 47% of parents and less than 7th grade in 20%. After parents were given one of the pamphlets to read, their reading time, comprehension, and attitude toward the pamphlet were measured. Mean comprehension was 15% lower for CDC than for LSU (56% vs 72% correct; P < .001) and reading time was three times longer for CDC than for LSU (13 minutes 47 seconds vs 4 minutes 20 seconds; P < .0001). These trends were significant for parents reading at all but the lowest levels. Mean comprehension and reading time did not differ among parents reading at the third grade level or less. However, mean comprehension was greater and reading time lower for LSU among parents at all reading abilities greater than the third grade. Parents in the private practice setting took the longest time to read the CDC (20 minutes 59 seconds vs 5 minutes 46 seconds, LSU), yet their comprehension on the LSU was significantly higher than on the CDC (94% vs 71%; P < .0001). Two focus groups of high-income parents were unanimous in preferring the LSU. A short, simply written pamphlet with instructional graphics was preferred by high- and low-income parents seen in private and public clinics. The sixth grade reading level appears to be too high for many parents in public clinics; new materials aimed at third to fourth grade levels may be required. The new 1994 CDC immunization materials, written at the eighth grade level, may still be inappropriately high. The American medical community should adopt available techniques for the development of more effective patient-parent education materials.
Article
To evaluate the effect of cartoon illustrations on patient comprehension of and compliance with ED release instructions. A prospective, randomized, controlled study of consecutive patients who presented to the ED of a community teaching hospital with lacerations necessitating wound repair during a three-month study period. At ED release, the patients were randomly assigned to receive wound care instructions with or without cartoon illustrations. Three days later, the patients were followed up by telephone. A blinded investigator asked a series of questions designed to test the patient's recall of, understanding of, and compliance with wound care instructions. A total of 234 patients were successfully contacted by telephone; 105 (45%) had been given ED release instructions with cartoons, 129 (55%), without cartoons. There was no significant difference in age, gender, level of education, or satisfaction with the ED visit between the two groups. The patients given cartoon instructions were more likely to have read the instructions (98% vs 79%, p < 0.001), were more likely to answer all wound care questions correctly (46% vs 6%, p < 0.001), and were more compliant with daily wound care (77% vs 54%, p < 0.01). Subset analysis of those patients who had less than a high school education (n = 57) demonstrated even larger differences between the two treatment groups in terms of comprehension of and compliance with ED release instructions. Cartoon illustrations are an effective strategy for conveying information and may improve patient compliance with ED release instructions.
Article
In this study, culturally sensitive visual aids designed to help convey drug information to nonliterate female adults who had a prescription for a solid oral dosage form of antibiotic medications were developed and evaluated. The researchers conceptualized the educational messages while a local artist produced the visual aids. Seventy-eight female ambulatory patients were evaluated for comprehension and compliance with antibiotic prescription instructions. The study was conducted in three health centers in Cameroon, West Africa and followed a pre-test, post-test, and follow-up format for three groups: two experimental, and one control. All participants were randomly assigned to either experimental or control groups, 26 patients to each group. Subjects in the experimental groups received visual aids alone or visual aids plus an Advanced Organizer. A comparison of the three groups showed that subjects in the experimental groups scored significantly higher than the control group in both the comprehension and compliance measures.
Article
Pictographs have been used in nonliterate societies to help people remember spoken instructions and, today, they could be used to help nonliterate people remember spoken medical instructions. This study tested the hypothesis that pictographs can improve recall of spoken medical instructions. Twenty-one junior college subjects listened to lists of 38 actions for managing fever and 50 actions for managing sore mouth. One of the action lists was accompanied by pictographs during both listening and recall while the other was not. Subjects did not see any written words during the intervention and, therefore, relied entirely on memory of what they heard. Mean correct recall was 85% with pictographs and 14% without (P < 0.0001) indicating that pictographs can enhance memory of spoken medical instruction--often to a very high level. For this technique to be clinically useful, further research is needed on how to achieve accurate recall of large amounts of medical information for long periods of time by nonliterate patients. By viewing illiteracy as a memory problem, the large body of research on learning and memory can be utilized in designing education materials for this group.
Article
The present research explored the effectiveness of a picture and the phrase "even a penny will help" on contributions to charity. Two experiments were conducted, one in the laboratory and one in the field. In both experiments the manipulation of a pleasant picture and the phrase created four types of signs: (1) picture-no phrase, (2) phrase-no picture, (3) picture-phrase, and (4) no picture-no phrase. In the field experiment patrons of local business anonymously put money in a donation box that displayed one of the four signs. In the laboratory experiment, 129 undergraduate students were randomly assigned to view one of the four signs placed on a donation box for a local charity. Analyses for both studies showed that more money was donated when the boxes displayed pictures. The phrase "even a penny will help" had no significant effect on donations.
Article
Previous research has demonstrated that a pleasant drawing (a smiling face) on a restaurant bill increased the number of tips left by clients. A similar experiment was carried out using a drawing of the sun since it is known that tips increase on sunny days. The experiment was carried out in local bars and involved clients who have ordered an espresso coffee. Analysis showed that the drawing of the sun led clients to leave a tip more frequently than when this drawing is not present. The size of the tip left was also higher. The hypothesis of the creation of a positive frame of mind by this stimulus is discussed.
Article
An inability to read and understand written medication instructions may be a major contributory factor to non-compliance in certain patient populations, particularly in countries with a high illiteracy rate such as South Africa. Twenty three pictograms from the USP-DI and a corresponding set of 23 locally developed, culturally sensitive pictograms for conveying medication instructions were evaluated in 46 Xhosa respondents who had attended school for a maximum of 7 years. Respondents were tested for their interpretation of all 46 pictograms at the first interview and again 3 weeks later. The correct meaning of each pictogram was explained at the end of the first interview. Preference for either the Local or USP pictograms was determined. At the follow-up interview, 20 of the Local pictograms complied with the ANSI criterion of >/=85% comprehension, compared with 11 of the USP pictograms. Respondents indicated an overwhelming preference for the Local pictograms.
Article
There is a growing need for balanced drug information customized for special target groups such as children [Food and Drug Administration. Prescription Drug Product Labeling; Medication Guide Requirements; Proposed Rule. Part VII. Department of Health and Human Services, 21 CRF Part 201, et al. Federal Register 1995;60:44182-252; Dickinson D, Raynor DK, Duman M. Patient information leaflets for medicines: using consumer testing to determine the most effective design. Patient Educ Couns 2001;43:147-59]. Pictograms are one aid that may be used to make information easier to read and understand. The aim of this study was to test whether children understand pictograms developed by the United States Pharmacopeia (USP) [The United States Pharmacopeial Convention Inc. USP Pictograms. Retrieved 11 March 2002 from http://www.usp.org/], and especially, if the pictograms improve children's understanding of medicine leaflet information. Finnish elementary school children aged 7 years (n=28), 11 years (n=31) and 13 years (n=31) were interviewed and asked what they thought 15 USP pictograms mean. The two older age groups were also asked to read an "easy-to-read" leaflet for penicillin-V. Every second child was given a leaflet with a plain text and the others received the same text accompanied by pictograms. After reading the leaflet, the children were asked seven questions related to the text. Most of the children understood the meanings of the selected 15 pictograms correctly, the proportion of the correct explanations varying from 30 to 99% according to the pictogram. Even well-understood pictograms did not help the children understand the leaflet information, although they reduced the need for probing. This study shows that the context in which pictograms are tested makes a difference in the results. Testing plain pictograms without incorporating them in their real context, e.g., in the patient information leaflet may exaggerate their usefulness in leaflet information.
Article
There is broad acceptance of the philosophic foundations of health education as grounded in the collaborative model of client and professional partnership. In practice, however, this partnership is largely dominated by the professional side. Workers may be particularly sensitive to professional domination as issues associated with health promotion vs. safety and health programs at the workplace are often politicized. This polarization is particularly evident in the area of asbestos-related hazard prevention, reduction, and education. Using asbestos hazards as the unifying theme, we participated in a program to facilitate active participation of workers in the production of their own occupational health education materials through the use of the photonovel. Representatives from some seven building trade locals worked with a staff to produce a twenty-four-page photonovel for their co-workers. A random sample of 500 members of building trades locals received either a copy of the photonovel or a popular NCI asbestos pamphlet with an evaluation questionnaire. Differences between the groups were evident in favor of the photonovel in readability, factual recall, general credibility, and attitudes toward future involvement in health and safety issues.
Plain language needed
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Patients comprehen-sion of polio information pamphlets
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The cartoonindoctor–patientcommunication.Furtherstudyofthearthritis and rheumatism council handbook on gout
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Practice implications: a summary of recommendations for using pictures in health education
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Theoretical context..................................................................... 188 8. Practice implications: a summary of recommendations for using pictures in health education...................... 188
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Example of picture with text and caption from American Geriatrics Society's Eldercare at Home booklet on managing medications. (From Houts (Ed.) [29], used with permission)
  • Fig
Fig. 6. Example of picture with text and caption from American Geriatrics Society's Eldercare at Home booklet on managing medications. (From Houts (Ed.) [29], used with permission).
Special Interest group on reading and readability
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