Using Pictures in Health Education, January 8-12, 2007


Members on this list have shown much interest in creating health education materials appropriate for patients with low literacy skills, and in the use of pictures to enhance these materials.

Our guest speakers were Len and Ceci Doak and Dr. Peter Houts, who have recently published a peer reviewed article assessing the effects of pictures on health communications. The article presents summarized findings from reviews of more than 500 journal articles and other publications on this subject. The Doaks are also authors of "Teaching Patients With Low Literacy Skills", which describes some of the earliest health literacy research, along with practical techniques for communicating clearly with patients.

A week before the discussion, we asked subscribers to share their concerns about using pictures for health education, so that we could get a sense of what to cover in the discussion. We got many responses, which voiced concerns about these areas mostly: 1)Resources and availability of visuals, 2) Competing with the market place, 3) Thinking visually; lack of personal artistic ability.

The guest speakers reviewed the research findings about how pictures can improve patients' attention to materials, recall of the information, understanding of the information, and tendency to act on this new information. They also discussed how to plan the design of materials using a "Visuals Spec Sheet", how to find low cost illustrators and photographers, how to use captions effectively, and what kinds of pictures work best. Other people also shared experiences in producing effective picture-based materials at low cost. We discussed the use of photonovellas as teaching tools, and use of picture-based materials in adult literacy settings as well as health care settings


Recommended reading

Teaching Patients With Low Literacy Skills

The role of pictures in improving health communication: a review of research on attention, comprehension, recall and adherence

Houts, PS, Doak CC, Doak LG, Loscalzo, MJ. Patient Education and Counseling, 61 (2006) 173-190
Erratum note with corrected graphic

Using pictures to improve health communication

Presentation by Peter Houts, PhD


List Events

Cecilia Conrath Doak, M.P.H.

During her 24 year career as a commissioned officer in the U.S. Public Health service she developed and led health education programs in diabetes, the Pap smear, smoking and cancer, and others. She received the Surgeon General's Commendation Medal for her work in cancer education for the public. She retired as director of continuing education for physicians and allied health personnel.

Her second career is with Patient Learning Associates in health literacy. Together with husband Len Doak, she has presented over 200 one and two day workshops and trained more than 11,000 doctors, nurses, and other health professionals. She is the lead author of the award winning book, "Teaching Patients with Low Literacy Skills."

As a volunteer tutor, she worked for five years in the inner city Washington, DC, and was for 2 years a volunteer teacher of adults aspiring to a GED. She served for several months as a consultant and team leader in East and West Africa on public health and malaria projects.

Leonard G. Doak, BSEE, PE

Leonard comes to health education via adult-education, after serving 14 years as a volunteer literacy tutor of adults. He is a former national president of Literacy Volunteers of America Inc. His engineering career includes simplifying instructions for Navy crews on ships and submarines, as well as engineering project management. He was also the manager of marketing for an aerospace firm.

Together with Ceci Doak, he has analyzed the suitability of over 2,000 health care instructions in all media, and is co-author of both editions of their book and a number of journal papers on health literacy. In 1978 he was cofounder of not-for-profit Patient Learning Associates Inc. with a mission to help train the health care community to make their messages to patients easier to understand and more motivating.

Peter Houts, PhD

Peter Houts, PhD, is a social psychologist who has conducted research on how patients cope with illness for over 25 years. He has developed and evaluated innovative interventions to help patients and their family caregivers cope with illness. He has also directed surveys of cancer patients' problems and unmet needs. Beginning in 1989 he collaborated with Drs. Arthur and Christine Nezu in adapting problem-solving therapy for depression to address the needs of cancer patients and their families. This led to his editing Home Care Guides for Cancer, HIV/AIDS, and for Care of Elderly People at Home which support problem-solving by patients and their families. Dr. Houts also developed the psycho-educational COPE Model which is widely used in applying problem-solving to coping with illness. Recently he has collaborated with Len and Cedi Doak in studying the usedical communication to people with low literacy skills. Dr. Houts has published over 80 articles in peer-reviewed journals, has authored or edited eight books and serves on the editorial board of two journals concerned with psychosocial issues in patient care. He is currently a retired professor from the Pennsylvania State University College of Medicine and continues to consult with research projects applying problem-solving education and counseling to health care and utilizing pictures in health communication.


Preliminary Concerns

This message went out a week before the discussion to get a sense of what concerns people have in using pictures for health education:

Hi Everyone,

It's time for Wednesday's question, and I want to prepare for next week's discussion by getting us thinking about the use of pictures and visuals in passing on health information. Whether it is during a clinical appointment, or more formalized health education setting, there are lots of ways to present health information. What do you see as the biggest problem in getting health educators to use more visuals in their instructions?

Think about your own experience and let us know what you think. Send a brief answer this week, and we'll discuss it further with our guest speakers next week.

Julie McKinney

Discussion List Moderator


To me one of the biggest problems is to find pictures that do not have
copyright to be able to use them in brochures.

Elba I. Nieves MSN, RN CE

Caribbean Healthcare System

Nursing Patient/Family Health Education Coordinator, Inpatient Diabetes Educator


I'm with Elba. Is it easier to set up consent forms/release forms and take photos or videos yourself, or shell out the cash to a stock-photo/video company? Which is better?

Boyd Davis


1. The lack or artistic ability and/or 2. The lack of access to
someone with that ability.

The problem is that "thinking graphically" is not a skill that we are
all born with. There is a lot of information out there about "just use
simple graphics" and how you don't have to BE an artist to do this.
However, many people cannot plan or think in graphics mode.

We probably need more step-by-step approaches to doing this. I suspect
most people will agree that it's a good idea, but it can be really
intimidating if you were the kid in school who always hated art

Jan Potter


The lack of available free internet based clip art that is appropriate and able to used in health education is a barrier for those of us who would like to include illustrations and artwork, but who can't see to find pictures that depict our points. If there were free available visual (clip art) on the internet we could easily download and use these visuals more extensively.


Mindy Domb | Director | HIV/viral Hepatitis Integration Programs | SPHERE/SHHIP | HCSM, Inc.


The following are problems I see with getting health educators to use
visuals in their instruction.

- Time needed to search for and develop deliverables.

- Utilizing graphics that transcends cultures

- Utilizing graphics which are age appropriate

Melissa Hodge-Penn, MA

Health Literacy Coordinator

DTAE/Office of Adult Literacy


Hi everyone! This is my first post to this list serv, although I've been following the discussions for several months. I work in public health research in rural West Texas, and one of our areas of interest is health literacy. I am planning on going to graduate school, getting my MPH, and finding work in the health education field so all of this is of interest to me for both current and future work.

Regarding the Wednesday question, I agree with what Ms. Hodge-Penn said. One possible solution might be to take advantage of local talent. While I am not an artist, I have access to talented artists through the local universities, colleges, and primary and secondary schools, as well as the community art groups. This also might help with creating visuals that are relevant for the specific cultures and age groups represented in your target groups. For example, my 11-year-old sister is very talented in drawing anime/manga characters, and I've been brainstorming ways that she might use that talent to convey health messages to kids her age who are interested in that style of art. Has anyone on here had any success with this kind of strategy?

Erin Braddock

Senior Analyst

West Texas Rural EXPORT Center


Graphics are worth a thousands words -- unfortunately, they may be
interpreted incorrectly and even sometimes as the opposite message.

On over-the-counter medicines, we learned the symbol for "no", (circle
with diagonal bar), was frequently misunderstood to mean the opposite on
over-the-counter medicines! Such as; the no sign over a pregnant women
meant to symbolize do not take while pregnant. Some reported it meant to
take while pregnant. The label on a tank of oxygen showed a graphic of a
burning match meant to symbolize flammable. Some reported the product
must be heated.

Utilizing graphics/visuals is challenging because of the translations
within "any" culture. I feel until there are public health graphics and
symbols that are universally tested, graphics are best used to make
publications appearance friendly. And the objective; appearance
friendly, is significant.

Even graphic colors have a targeted use. History shows primary colors
are reserved for very young folks and seniors because they attract
attention and are easy to see. Pastels are reserved for teenage females
and younger women. Pastels often fade from appearance on publications
read by seniors because of seniors loss of depth perception.

Does anyone know of any public health graphics that are universally

Marcia L. Trenter

Special Assistant to the Office Director

Office of Training and Communications

Center for Drug Evaluation and Research

U.S. Food and Drug Administration


Some of my challenges include:

-If we need to go back and change artwork or add additional pieces, we can't always find the same artist or the original source.

-With a lot of searching, I have been able to find some free clipart online. Unfortunately, I usually see the same clipart/photos in documents of other agencies and organizations. That can be confusing for clients when materials start to look the same.

-We know that photos are often more clear in the message and feel more applicable for our readers. Bit its hard to find photos that represent the issues we're addressing. Its one thing to find a photo of child, a whole different issue to find one of a child using a medical device, an adult using testing their insulin, etc.

-On the tech side, once I find the images, working with them isn't always easy. I sometimes have limited software options and I wasn't professionally trained in working with graphic images.

Thanks for touching on the the topic! I know there are more resources and ideas out there, and I'm looking forward to hearing from other folks!

Megan Sety

Public Health - Seattle & King County

Environmental Health Services Division

Tacoma Smelter Plume Project



I am interested in what the research is showing in the use of stick figures in patient teaching - also in the selection of colours in graphics.

I also want to say that I have used the "Teaching Patients With Low Literacy Skills" for more years than I care to admit. It has been a wonderful resource and I am very grateful to the authors. Also, thanks for hosting this discussion.

Nancy Simpson


This is my first time to post as well. Interesting topic. I am very intrigued at our use of visuals in the public health field. We are exposed to so many visually and emotionally stimulating marketing items everyday. I find it a daunting task to create visuals that will stimulate learning or behavior change in an already over stimulated society. As a nutritionist for the WIC program in TX, I always wish I knew more on marketing strategies. I'd like to know how the junk food companies market to kids so they'll beg their mom's buy more chips and candy. Are we (public health) using this same marketing strategies with our visuals?

Pam McCarthy, RD from Massachusetts WIC has worked with a marketing firm to develop visuals that use the marketing strategy of emotional messaging for public health issues. The back of the visual features learning points about the picture. In my opinion these are the most innovative visuals I've seen in public health. Unfortunately, I don't have a link to her materials. They should be on the following website soon. I will attach an example of the front of two of the visuals to this email.

Best Regards,

Rebecca Turnbow

Nutrition Education Consultant



The two examples you attached of emotional messaging for public health issues are terrific.

If public health agencies and organizations had the mass amounts of money that junk food companies do we could flood the market with strategic marketing messages. The National Institutes of Health (NIH); brain, eye, mental health, etc. are the exception.

We need to leverage our knowledge to create partnerships for funding for intelligent design, production and distribution.

Thanks for sharing.

Marcia Trenter


I just located two interesting websites for unversal health symbols which might be of interest to this discussion. Both point to the need for research to identify universal public health symbols.

The first is a RWJ site discussing a project they supported for hospital symbols

and the other is the site for the Society for Environmental Graphic Design which helped them with the project.

Bertie Mo, Ph.D., MPH



I'm very interested in the use of visuals in health education so I'm really enjoying everyone's comments.

One challenge in using visuals in health education is finding ones that send appropriate messages about persons with disabilities. I've seen visuals that inadvertently send the message that persons with disabilities are helpless, passive, and/or victims. I've also seen visuals that show equipment being used incorrectly so they don't serve as good educational models. I think it's valuable to ask persons with disabilities review existing visuals that you are thinking of using or provide input into planning a photo shoot to make sure the visual isn't perpetuating a stereotype or illustrating incorrect actions. If there are resources to do your own photo shoot, I think it's best to use people with disabilities instead of persons without disabilities posing as having a disability. Sometimes, it can be obvious that the person does not really have a disability and to use someone without a disability might lead to a lack of credibility for your whole message.

I'm looking forward to learning more about visuals from others on this listserv!

Martha Alexander


Those are the preliminary concerns. Now follows the real discussion

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