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

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

Discussion Summary | List Events | Preliminary Concerns | Resources

Full Discussion

Hello Everyone,

Welcome to our discussion about using pictures in health education for low literacy populations! We have with us Len and Ceci Doak and Dr. Peter Houts, who have studied this topic extensively, and recently published a comprehensive review of related research. Please see below for more information about their experience and this research review.

During this week they will present some of their findings in studying the use of pictures in health education and communication with low literacy populations, and they will also try to address your questions. Please keep in mind that this is not a "live" discussion: the timing of responses will depend on when the speakers and subscribers have a chance to compose their messages, and when the moderator can send them through to the list. We do not expect anyone to be sitting at their computer at every moment, so please be patient if responses do not come immediately. Also, please keep in mind that Len and Ceci are on the west coast, so there is also a time difference!

I am so pleased to have Len, Ceci and Peter addressing this important issue with us all, and I very much look forward to your particpation this this discussion!

All the best,



Hi - I'm Peter Houts - and I'm looking forward to sharing some of what I
have learned while working with Ceci and Len Doak about how to best use
pictures in health communications. I realize that health communications
is a very broad subject and my expertise is primarily in how to
communicate directions for managing illness - both to patients and to
family caregivers.

The work that we did together was published as a literature
review: Houts, PS, Doak CC, Doak LG, Loscalzo, MJ. "The role of pictures
in improving health communication: a review of research on attention,
comprehension, recall and adherence" Patient Education and Counseling, 61
(2006) 173-190

The PDF file that Julie will make available is adapted from a slide talk
that I will be giving to the American Psychosocial Oncology Society in
March. It is intended to spark interest in using pictures among people
who study how patients cope with cancer.

I have been reading the messages that people posted before our session
officially began and here are some of my thoughts in response.

With respect to clip art - I have NOT found it useful to use clip art or
art done for purposes other than the one I am trying to illustrate. The
reason is that the art should be closely related to the text in order for
the viewer to link them and in order to have maximum impact on people's
comprehension, recall and behavior change. Art that does not relate
directly to what is being said has been shown to have no effect on
comprehension, recall, or behavior. Many patient education materials do
use "warm fuzzy" art, but little is gained other than possibly drawing
attention to the document. In the case of poor readers, they are likely
to be confused by art that is unrelated to the information being conveyed.

I agree very much with the points made by Marcia - that pictures by
themselves, without explanatory text, are likely to be interpreted in many
different ways by viewers. That is why text - simply written - should
always be closely linked to art. As I say in the slide show - the use of
pictures should build on a foundation of clear, simple writing.

In reply to Nancy Simpson's questions about stick figures - I have found
that they work very well. Both of our research studies used stick figures
and, not only did people remember their meanings, the study participants
spontaneously said they enjoyed working with them. One advantage of stick
figures is that they are culturally neutral. (You can see examples of the
stick figures we used in the pdf file of my slide show.) One objection I
have heard to using stick figures was from a person who showed our
research drawings to health educators in Africa who said that very thin
people were thought to have AIDS. They suggested making the lines thicker
so the figures did not seem emaciated. My other experience with stick
figures was in asking people in focus groups what kind of pictures they
preferred in the "Eldercare at Home" book that I edited. In the focus
group, people said they wanted color pictures of people who look like
themselves. This was not possible given the diversity of the intended
audience and the expense of creating the pictures. I, personally, think
that what people say they want in a focus group is not necessarily the
same as what works in the real world. I suspect that those focus group
participants would have responded positively to stick figures if they were
linked to information they wanted to learn.

As to the cost of creating art - there are many people who are skilled at
drawing and who will work for reasonable rates. For the Eldercare at Home
book, it took about 20 minutes per drawing when I sat with the artist,
explained what I wanted, and responded to his draft ideas. Once he
understood the kind of drawings I wanted, I was able to communicate with
him by FAX which saved both of us travel time. I believe we paid him $50
an hour which meant that each drawing cost roughly $20. This was a very
reasonable rate in view of the fact that we generated over 200 drawings
for that project. It is important that the health educator be the
person who decides what should be in the drawings - not the artist. This
means you will have to work out in your mind what you want the drawing to
include before talking with an artist and then give feedback to his/her
sketches until you have what you want.

Peter S. Houts, PhD


Dear colleagues and friends,

We thank you Julie for the opportunity to discuss ideas and research on using pictures in education; especially health education. We (Ceci and Len) are honored to share this task with Dr. Peter Houts.

Our thanks also go to those who took the time to write about problems, questions and concerns on using more pictures with instructions. And for those who have already offered helpful suggestions and information sources, we thank you.

A brief preamble:

There may be three parts to a health care instruction: 1) the words (spoken or written), 2) picture captions, and 3) pictures and demos. These apply to verbal and print instructions, to web sites, and partly to video. During this week, we'll discuss pictures and also their integration into the communication as a "package".

To carry the preamble a bit further, let's consider the particular characteristics of the reading habits of poor readers which can affect the learning potential from visuals. There are four we can consider: 1) their eyes wander about the page without finding the central focus of the visual; 2) skip over principal features; 3) eyes may focus on a detail such as the color of nail polish on a finger using a syringe or an A frame house in the background; 4) slow to interpret perceptual information and interpret the visual literally. (our book 1996, p.. 93)

We plan to address each of the issues you raised last week. We have some specifics about how to "think visually" as well as addressing some of the characteristics described above. This is such an exciting topic and we are delighted to be a part of sharing concerns and experiences.

The comments and questions seemed to fall into 3 groups: 1)Resources and availability of visuals, 2) Competing with the market place, 3) Thinking visually; lack of personal artistic ability. We and Peter will address these during the week. We encourage and welcome your feedback during the process.

Our responses to comments:

A key concern is the availability of free or non-copyright, appropriate pictures. (Appropriate for topics, genders, age, culture, etc.)

OUR COMMENTS: Several respondents last week already offered suggestions for sources for visuals, and nearly all government agencies have pictures included in instructions that can be used without cost. These can be obtained by websites, from brochures and videos, and by contacting the agency. But these do take time to ferret out.

Suppose you are assigned to write a summary two page instruction, to give to asthma patients at your medical center, on key points of how and when to use their inhaler. The schedule allows you a week during your "free" time. This topic fairly cries out for the messages to include pictures. We suggest that if you can't find suitable visuals that you buy them, and according to your specification. (Later this week we will offer a spec sheet format to help you define and buy the visuals you want. We believe that Dr. Houts will offer comments on how to buy pictures, their potentially very low cost, and short turn around time to get them.)

We'll elaborate on this in the coming days.

best wishes,

Ceci and Len Doak


I have discovered that many of the publications offered from the New York State Health Department and the Office of Children and Family Services are not written at the level of so many of the parents of children.
Would Mr. & Mrs. Doak and Dr. Houts be available to make recommendations (consult) to State agencies if requested? It is easy for forms to be outdated but also just as easy for publications, brochures and pamphlets to be originally written at college level with the target population at fifth grade literacy level. The state has been successful in offering written culturally sensitive material but has not addressed the literacy problem.

As of this morning, it was announced via radio that our outgoing governor has arranged for many publications to be printed with his name and/or picture. Due to the cost I am sure we will have to use these before more can be made. Any ideas on what can be done?

Crystal Clough



I'd like to share some comments supporting your observations on the value
of alternative graphic designs in health education.


1) We use clip art only in very specific situations, such as illustrating
actual sizes of food portions for people with diabetes. Clip art that does
not support, reinforce, or relate to the topic being discussed is
ineffective at best and misleading or even harmful in some situations;

2) I certainly agree with you and Nancy that stick figures can be very
useful with selected audiences. The key is researching a representative
sample of end-users to ensure the 'majority' of recipients understand the
messages being conveyed and accept the simplicity of the graphic approach.
However, as you point out later, illustrations can often be obtained at
fairly low cost in many situations, so unless it is absolutely necessary,
try not to limit yourself to this approach.

3) Re stick figures, the one objection you mentioned from an educator in
Africa that using thin stick figures may be problematic as very thin people
were thought to have aids, does offer an opportunity to comment on some
issues that come up in many projects;

a) Is a new and interesting observation valid? Input obtained in interviews
or focus groups may sound true, real, or logical, but are they relevant to
the majority of intended users of your program? Group interview results
often suffer from "the loudest voice in the room" problem. Unless they are
run by a skilled facilitator, the input of one or two persons can often
dominate a group. Common sense, probing for additional information or bias'
among a broader mix of group members, or trial and error are sometimes the
only recourse.

2) How valuable are focus groups results? This is a difficult question to
answer (as Coca Cola found out when then launched their New Coke after
literally 100's of consumer focus groups and found they had made a major
strategic mistake). Focus groups offer qualitative input on a subject that
provides information for "further investigation" - information that is not
necessarily projectable to the universe or audiences you are interested in

As for budgets, culturally-neutral graphics, and other obstacles often
encountered in trying to incorporate graphics into a program, your
observation that you can do a lot with very little money have been my
experience as well. One should also not assume, without testing, that
graphics that are not culturally sensitive will not work with an audience.
A medical missionary recently had a number of our programs tested by native
educators working with patients in diabetes clinics in Tanzania. The text
was simply written and the graphics were relevant, but almost all of the
graphics were of white males and females. Although different graphics would
obviously have been better, the need for relevant materials patients could
understand and use to improve their diabetes-self care far outweighed the
skin color used in the graphics.

Finally, as you point out Peter, working out what you want to achieve with
each graphic element (drawing, illustration, photograph) before you meet
with the artist is very important. You must guide the development process -
not the artist.

Paul Tracey


Excellent site, thanks

Elba I. Nieves MSN, RN CE


Paul - I agree with all of your comments. I, too, have been misled by
focus groups for the reasons you mentioned. The real test of pictures
should be by having people use them. Pilot testing is more reliable than
focus groups.

There is another issue we need to keep in mind - the image that the
organization producing the education materials wants to project about
itself - and this was mentioned by Ceci and Len Doak as well in talking
about supervisors. While stick figures would have worked as well in the
Eldercare materials, the American Geriatrics Society wanted something that
looked more "professional." So we ended up with simple line drawings that
looked like real people. To address the problem of ethnicity and gender,
we consciously included an equal number of Latino, African American, and
Caucasian figures in each chapter. So far I have not heard any complaints
about ethnicity in those materials.

I think that Paul's point about using Caucasian figures in Tanzania because
they did the job and were available is important. The average person who
is seeking help will usually overlook "politically correct" issues because
the materials give the information he or she needs.

I want to thank Sunil for sharing his article. I will read it with great
interest and share my thoughts - hopefully tomorrow. I wish that we could
have sent our review article to the list surv as a pdf file - but I don't
have it in that format. I sent an email to the journal's editor asking if
he can get me a pdf copy. If he does, I will send it out on the list surv
as well.

One additional thought I want to share is about using photographs. I have
seen some excellent photo novelas that tell a story about changing health
behaviors (such as encouraging Latino women to have mammograms). When they
include pictures of people like those in the intended audience, then
viewers can identify with the characters in the story which should help
make the message stronger. The photo novelas that I saw also used text -
largely in the form of speaking balloons - to insure that the viewer
understands the intended message. My hunch is that photo novelas can be
very effective. However, when writing our review article, I could not find
tightly controlled experimental/control studies that proved this. Some
rigorous research on photo novelas would be an important contribution to
our field.

We considered using photographs in the Eldercare materials and rejected
them for several reasons. First is the problem of representing different
types of people. Photographs are so detailed that they give viewers many
reasons for saying "they're not like me." Second, as I mentioned in the
slide talk and was mentioned by Ceci and Len as well - people with poor
reading skills are especially likely to attend to irrelevant details and
photographs are loaded with detail. While photographs are very good at
gaining attention and for generating emotional responses, but they are less
good at controlling how viewers interpret the message. Simple line
drawings combined with simple text are the best way to insure that the
audience is interpreting the picture the way we intend. Marcia Trenter
made an important point in her earlier message - about how pictures, by
themselves without accompanying text, can lead to many and often unintended
interpretations. I'm attaching a cartoon from the New Yorker that makes
that point too.



What a terrific topic to take up on the listserv. I'm looking forward to
learning more from everyone, and want to thank Dr. Houts and the Doaks for
their longstanding contributions in this area.

I'd like to point interested readers to another potentially useful reference
on the use of pictures in healthcare. My colleagues and I recently published
a review on the use of illustrations for educating patients about medication
use. The reference follows, and I have attached a pdf of the article.
Hopefully, it will go through.

Katz MG, Kripalani S, Weiss BD. Use of pictorial aids in medication
instructions: a review of the literature. Am J Health Syst Pharm 2006;

All the best,

Sunil Kripalani, MD, MSc

Assistant Professor

Emory University School of Medicine


Dear J. Potter, Rebecca, and the list,

Obstacle: "lack of artistic ability", "lack of access to artists", "How
can the health care community compete with the commercial community ads?
People are already over-stimulated." Another obstacle, not mentioned, is our
possible perception that our supervisors won't be enthusiastic about our putting
in pictures, making the instruction appear less formal.


- These are real life obstacles and logical mind sets. Let's talk about
what you really can do about them. Sure, we'd like to get the huge benefits
for our patients that Peter listed, but how?

- You're right, relatively few of us are trained as artists; our education
process drills us in communicating by writing and somewhat by speaking. We
can write, we can explain verbally, but "art"? - Ugh! OK, so let's get
there on the strengths that we have. Here are some ways to do that:

-- Think about what you want the patient (or student) to know and do, who
the patients are, and where they are starting from. Here is a Spec Sheet for
Visuals that we developed to give structure to this information:
Specification for Visuals

- Date, Document title, Author/client name

- Intended audience: genders, culture, knowledge of subject, age, other

- Key purpose: to introduce topic, to explain a process, to persuade, to
maintain action, ...

- The key message the visual is to show: (ex. "give insulin shot in upper

- Caption (prelim.): (ex: "Puff up skin; hold needle at a slant; give quick

- Key text that relates to the visual:

- Approx size & media:

- Schedule & cost

- Comment lines from illustrator

The above can help you think about what you want, and greatly direct the
illustrator (and a purchasing agent from your organization) so that you get a
suitable visual. And you will save time. Peter suggested that if possible, you
should talk with the illustrators as they are beginning and formulating
ideas. We have found this very helpful. Typically, he mentions costs of $20 to
$40 per picture. Simple line drawings work well, and can be sent to you by
FAX from local or outsourced illustrators.

Find illustrators in the yellow pages, on Google, at your local community
college - they are available.

Supervisors can be brought around to accepting more pictures in health care
instructions by citing the huge benefits shown by the research, and what
these benefits could mean to your patients (students) and organization. And the
cost and time factors are small.

Does this help? We'll talk about effective and low cost ways to assess
suitability of your visuals in a coming posting.

best wishes,

Ceci and Len


Thanks for these really helpful and useful tips!

Boyd Davis, UNC-Charlotte


I have found that students with a major in Graphic Art or Communication at your
local community college or college
can be a good resource. They can be very responsive when this involves a
requirement for a school project.

Michaud, Jacqueline M., R.N


Thanks, Maricel, for bringing adult education into this discussion. I,
too, believe that the disciplines of adult ed and health ed have so much
to share. As you mentioned, all that we are learning about using
pictures can apply to beginning ESOL teaching as well. Pictures can also
be a great way for any literacy teacher to generate discussion,
vocabulary, critical thinking, sorting of information and reading and
writing skills practice, either about health issues or other topics.

I'm also glad that Peter brought up photonovelas. Does anyone have
experience using them with adult learners or patients?

Julie McKinney

Discussion List Moderator



You again raise some interesting topics that readers have probably
encountered or wondered how to handle.

Depending on the literacy level of the reader, the "that's not me"
objection to photographs, which is often a hidden objection uncovered in
the testing process, can seriously limit the effectiveness of a program.
This is much more of a problem than many people realize - especially among
low literacy audiences - so your mentioning it was very important.

The Doaks' observations that one should be careful to avoid using
photographs (or any graphic) with irrelevant background details is also
important. On the subject of photographs in general, it may be useful to
note that there is no solid evidence to my knowledge that photographs, in
general, are superior to good illustrations in health education programs.
There is no need for many educators to feel they are "stuck" with using
illustrations because they cannot afford photography. In my own case,
because of the high cost of a photo shoot and/or limited supplies of
royalty-free art that meet the specific needs of a project, I have moved
away from using photography and use color illustrations almost exclusively
for the reason Peter noted (you have better control over
how the reader interprets the message).

The one exception to this would be photonovellas. I have worked with these
and found them to be highly effective - especially with Spanish-language
readers. They are very popular with many juvenile and adult readers from
Mexico and some Central and Latin American countries (as are comic books,
which are also be very effective with low literacy audiences). An added
benefit of producing this type of program is photonovellas have a
longer-life span than many other types of programs as traditionally they
are passed along to others. This added reach and effectiveness helps to
offset the one big downside to photonovellas. They are expensive and time
consuming to produce. Unfortunately, this is a killer for most of us,
including me, but if any readers can afford them, they can be very
effective when addressing certain health topics.



Thank you all for your input on this topic. We here in Texas are beginning a new project where we will be dealing with a great deal of non-English speaking people that we are responsible for bringing services to. Your suggestions have been very helpful to us. I am sorry that I don't have something to offer to what has already been presented. I just wanted to thank you all for what you have offered. So, THANK YOU!!!!!!

Lynn E. Bernhard, B.S.,C.M.

Director Galveston County CBO CHIP/Children's Medicaid

Chair Galveston County Community Resource Coordination Group


Dear list serv,

Several questions dealt with assessing suitability of pictures - are they
understood and accepted by the intended audience? Focus groups were suggested,
but caution was advise to prevent making a decision based on "the loudest
voice" in the focus group. Also, what people say they want may not in reality
may not turn out to be what they want. Here are some practical suggestions
to respond to these issues.

Focus Groups versus one-on-one interviews: For community issues, for
example, environmental problems or general health promotion behaviors, focus groups
are useful and effective. However, for specific clinical instructions or
sensitive issues such as AIDS or STDs, the one on one interviews seem to be
more productive because the interviewer can probe answers, especially for
patients with low literacy skills. Another time to use one- on- one is to verify
the discrepancies that may arise in focus groups. In these instances,
verification with a sample of the intended audience is most helpful. For example,
we verified diet instructions for kidney dialysis patients directly in the
clinic while the patients were undergoing treatment.

The key question in testing visuals is "will the visuals (art work/graphics)
help or confuse the key points of the message?" Three areas to cover are:
(1) Let's look at the cover. What catches your eye?" (2) What do these
pictures tell you? (3)What do you think of the color? It is important that the
visuals portray familiar scenes or objects; this is why "modernistic" art is
less likely to be acceptable, it is not familiar. People need to be able to
identify with the visual presented and the action recommended. Types of
questions to ask are included in the chapter on "Learner Verification &
Revision" in Teaching Patients with Low Literacy Skills", Doak, Doak, & Root, p. 174.
This is available free, on-line at the Harvard School of Pub Health web

Another issue is that of cost and time needed to make such field tests,
especially the one to one assessments. The answer: Not very many - maybe 5 or
10. For example: While serving as consultants to their "Eat five a day" program
for seven different ethnic groups of Americans, the NIH statisticians
determined that 30 subjects (three different groups in one to one testing) was
suffiecient. In evaluating the verbatim comments to the test questions of those
who were presented with the draft instructions, we found that if anything
was wrong it showed up in the first ten subject responses.

Does this help?

best wishes,

Len and Ceci


Hi All,

I'm sure this is a naive question, but it seems that photos would be
easy and cheap to use for informal communication if there could be a way
to minimize the background interference and interpretation issues
mentioned. Paul noted the high cost of a photo shoot, which I suppose
you would need for a professional brochure, but could we use photos to
reinforce information in a clinical visit? The Doaks have mentioned on
this list how helpful it is for doctors to use even quick drawings
during appointments, but

Digital photos of medical equipment, syringes, body parts or even
medication could easily be organized on a computer, matched with simple
text, and then customized and printed out for patients. For example a
series of pictures --close-up with little in the background-- could be
used to demonstrate how to give an insulin injection. Or you could have
pictures on file of different common medications and put a photo of the
prescribed number of tablets of each kind, matched with the pictures of
sunrise, noon and sunset.

Would this be worthwhile and encourage more people to do it if it would
reduce the barrier of having to choose, hire and pay for an illustrator?
(Although we are hearing that it is a smaller barrier than most people
think!) Peter emphasized how helpful it is to use pictures to reinforce
spoken instructions, so would this offset the disadvantages of using
photos instead of simple line drawings? How could we make this most

I mention this because we have used this method as a family. My son is
fed with a feeding pump and takes a variety of medications, and we have
created instruction sheets for babysitters and caretakers using this
method of digital photos with text. It has very helpful in making them
less anxious about doing the feeding and medication, and is not too hard
to do.

Julie McKinney

Discussion List Moderator


I am relatively new to this list and have been following this discussion
with great interest, and appreciate the great insight and resources shared
to date. Thanks.

I wanted to thank Peter for raising photo-novelas as a resource for improved
health communication. We are currently involved in a collaborative project
developing continuing education for front line maternal child health workers
in frontier regions, many of whom have low literacy skills. After much
discussion, our project team (including community partners) decided to use
photo-novelas as an avenue to share success stories of community leadership
within our continuing education modules. The project is ongoing and we
expect to share our lessons learned once complete, but we too, are looking
for more literature/support/guidance for use of this approach.

Any suggestions for resources are welcome and can be sent directly to my
email address below. If I get several resources and there is sufficient
interest, I will be happy to post a synopsis of resources received to the
list. Just let me know.

Rhonda M. Johnson, DrPH, CFNP

Chair, Department of Health Sciences

Associate Professor of Public Health

University of Alaska-Anchorage


Hello all-

Lively discussion about photos and illustrations. As always, sage
advice from Len, Ceci, and
Peter. Julie also brings up a good alternative to pricey stock
photos-- doing your own!

I would like to share some of my challenges and good results with
cost photography. Like all of you, I like to keep my photo budget low
when possible.


A good digital camera in NATURAL, ambient can work.
However, due to deep shadows and color shifts that can happen with
in-door lighting and flash without professional lights, I suggest using
a duotone photos
(two PMS colors) or black and white photos with a pale color wash (a 5%
I've done it often and these techniques field test well with limited

You'll want to get a signed photo release from your subjects.
And make sure you don't use any photos for another more controversial
that could potentially embarrass your subjects. For example--using the
photo earmarked for
nutrition brochure a second time for TB or pregnancy brochure. In
short--only use the photo for the topic you
got the release for. A MUST!


Love their youth and creativity.
And, know you will need to be a "hands on" art production manager so
you don't get
loads of artsy shots that don't meet your health literacy needs.
Good rules of thumb?

1. BE VERY specific about what you are looking for. A photo
journalistic style is best versus wide-angle
lens or funky upshot approach.

2. Provide all the clothing for the model's yourself. Yep--iron them,
tag them, and have extras.
Free or low paid talent tend to show up in T-shirts or sporting
clothing with brands. Yes--I did have
a man show up in a JOE CAMEL shirt for a CVD brochure. Really.

3. Make a prop list and label all your props with masking tape (scene
1, scene 2 etc.)

4. Have a shot list and stick to it.

5. Have an assistant who marks down the shots you think looked best.


My favorite method to get the ethnically appropriate and behaviorally
oriented shots
we folks seek. And it can actually be very cost effective.

In the Washington DC-BWI metro area a professional photographer and a
trained photo assistant runs $1,200 to $2,000
a day. This fee includes getting your photos on disk.
Plan on getting 4 to 5 scenes (that means you may have to make a
waiting room look like a home . . .
per day. A day runs from 8 AM until 5 or 6 PM in most cases.
Expect your photographer to shoot 4 to 1 or 5 to 1. That means you will
get a good photo for every
4 or 5 shots taken.
Plan your shots, have your talent (people being photographed) come 30
minutes prior to their scene.
Have magazines lying around--the shoots and snacks! ALWAYS take longer
than expected.

Does it work? Yep--The Keenan team managed to get all the photo shots
for 24 booklets on TB (6 for
Pacific Islanders, 6 for Vietnamese, 6 for Hispanics, and 6 for general
population) in a 4- day period
at 10 sites. We emerged tired, yet with the shots needed to showed the
behaviors we wanted.


Don't be afraid of photography. Study the type of stock photos you
can't afford or
that don't quite have the correct look you meet. Strive to do them on
your own, with photography students,
or by hiring professionals.

I find it can be great fun for you and very rewarding to your readers.
Enjoy the new year!

All best,


Jann Keenan, Ed.S.

President, The Keenan Group, Inc.

Experts in Health Literacy


Thank you Lisa. Yes, there are 7 photonovels on prenatal care with an ESL component. Topics include: conception, going to the clinic, nutrition/WIC, risks during pregnancy, childbirth, newborn care, and breastfeeding. We are currently in the planning stages of a new bilingual (Eng/Spanish) photonovel on gestational diabetes. It should be available by December, 2007. see

We also recently developed a bilingual (English/Spanish) photonovel series for the National Good Agricultural Practices (GAPs) program out of Cornell University. They focus on food safety, a particularly relevant topic given the recent outbreaks of salmonella and E.coli. One is targeted to farmworkers re: hygiene in the fields. The second is a story of a family who gets sick from salmonella. It contains practical steps for all stages of food preparation (shopping, cooking, storing, cleaning) to prevent food contamination and to kill harmful bacteria in home kitchens. (it's such a practical reference- I keep one in my own kitchen!) There is also a special section for pregnant women on preventing listeriosis -an infection that can be fatal to an unborn child. Listeria is often in contaminated fresh/soft cheeses made from unpasteurized milk. Initially, these photonovels were available at no charge, now I think there is a minor fee. See

We learned a LOT during the extensive multicultural, multidisciplinary field-testing process. One lesson that stands out in my mind related to the current topic re: use of drawings and pictures - Is the thermometer and how to use it to test food temps. There was controversy about even including it - it was a must according to scientists. The perspective of those we came to understand as 'domestic cooking culture' (cuts across SES and racial and ethnic cultures) perceived it was not practical or culturally appropriate (e.g., few people have or use thermometers in home kitchens; too expensive for poor families to buy so not realistic or relevant; people have cooked for thousands of years without food thermometers) To make a long negotiation short, the balance point was the decision to eliminate the reference to using the temperatures as guide to tell if your food is 'done' to a more precise caption: "temperatures to kill harmful bacteria in meats" Note: the USDA does have a campaign that addresses the issue of 'doneness.'

Also, for the drawing of the thermometer related to food storage, we started with a commonly used illustration of a thermometer with cartoon-like drawings of bacteria. We discovered two things among the Latinos with the lowest literacy levels. One was they had some interesting interpretations of the personified bacteria drawings. Second they did not know how to read or interpret the numbers on the thermometer. For example, they did not know the low and negative numbers meant 'cold' and the high numbers meant 'hot'. So these things together made the illustration quite ineffective…consequently, the visual did not clarify the meaning of the text or help them understand what to do.

The men and women in the field-testing process gave us ideas for the changes needed to make the meaning of the illustration clearer. For example, we added a hot flame at the top of thermometer and ice cubes at the bottom. Instead of bacteria cartoons sweating/dead or shivering along side the thermometer- we included an oven plus 'too hot to live' caption and refrigerator/freezer plus 'too cold to grow'. (these visuals also help reinforce what to do.) In the middle, i.e., danger zone section, there are two steaks plus caption 'grows fast' (one has a few specks of bacteria with an arrow pointing to a second identical steak covered in specs) (The picture would be an easier and shorter way to explain.)

BTW, Thank you for the suggested outline for helping work with an artist to create a drawing. It is so critical to be clear about one's objectives when working with an artist and also for testing purposes to see if you've accomplished your goals.

One other note …I've been continuing my work re: how to teach with photonovels in a group setting using an empowerment-based, culture-centered process, with exciting results. It has helped me appreciate the fact that the spirit in which we use visuals and written communication in our work is also critical in achieving the broad aims of health literacy for individuals, groups, and communities.

Susan Auger

Auger Communications, Inc.


In an earlier message I said I would try to get a pfd file of the review
article that Ceci, Len, and I wrote. I was successful and it is
attached. There are two files - the first is the full article and the
second is an erratum explaining that one of the figures was incorrect and
includes the correct figure. I am very happy to learn about other
publications that have been mentioned in this discussion. I plan to read
them all.

I read the article that Sunil Kripalani and colleagues wrote and that he
included as an attachment to his email message. It is an excellent
article. I agree with them that age is a very important parameter for use
of pictures - research suggests that elderly people may react differently
to pictures - but we don't understand how differently and at what
ages. This is an important area for future research. I also think that
their observation on using complex icons is important. Some icons (such as
clocks) are not easily understood by people with low literacy skills. So
pilot testing is important to be sure icons are meaningful. In the study
with stick figures that I did, we made up some icons to try to make the
pictures more easily understood - but then found that the subjects often
had trouble remembering what the icons meant. It really gets back to using
simple language to explain what the picture or icon means. Icons without
explanation can lead to confusion.

I agree with Julie that photographs could be helpful and her example was a
good one - showing pictures of syringes or pills to illustrate
instructions. From her explanation, the pictures were probably very simple
- without a lot of distracting detail. The key is to keep distracting
detail to an absolute minimum. If that can be done with photographs, then
they will be very useful. But, as Paul mentioned in his email, it is often
easier to keep confusing detail down with simple line drawings.

I am learning a great deal from this discussion and am looking forward to
reading more of your ideas.

Peter S. Houts, PhD


Hi Everyone,

I am so grateful to all who have shared so much expertise on this
subject! I would like to encourage others to write in and share how you
plan to use the information shared during this discussion. In
particular, I'd like to hear from these different groups to see how it
may encourage you to do something different in your program:

--Health Educators

--Health Care Providers/Clinicians

--Adult Literacy Educators

--Policy makers

And if you have further questions for Peter, Ceci and Len, I invite you
to ask!

Also, I want to ask those of you on the health side: How can adult
literacy educators collaborate to enhance your efforts at improving
health communication? There is a large group of the most underserved and
least literate people who are being served in the supportive
environments of literacy classes. This group is also most in need of
health information and access to care. Everyone could benefit from this
type of collaboration, and so I would love to get feedback about how
this could work best.

Julie McKinney

Discussion List Moderator


Dear list,

What helpful comments from so many!

Thank you Jann for sharing your practical knowledge on taking photos for
health instructions. And of course this applies to almost any instructions.

And Susan Auger, your shared experiences about photo-novellas is so helpful -
thank you for taking the time to explain them to us. We especially applaud
your field testing comments. We too have found that even when the instruction
is developed by members of the same ethnic group, field teting with even a
handfull of the target audience can reveal so much.

Visuals - appearance - layout:

First impressions shape our behavior whether it is a printed page or a web
site screen. If the text looks dense, or the visuals cluttered, complex,
confusing, then people tend to pass it by. And this is true for all literacy skill


1) Jan V. White, Graphic design for the electronics age,

2) E.R. Tufte, Visual explanations,

3) D.H.Jonassen, The technology of text)

On a page with a visual and text, people tend to look at the visual(s) first,
and unconsiously decide if they will read further. If there is a caption,
people look at that next, and lastly they look at the text - if it is looked at
at all. So , captureing the viewer/reader with the visual and caption is all
important. You can make it easier for your readers/viewers by:

- Make the page look simple and easy to understand by showing simple
illustrations, and a minimum of text.

- Be consistent and logical in placing visuals vs. text.

- Cue the eye to look for your main point in the visuals. Use an arrow to
point, or enlarge it, or a bright color, or other attention getter to highlight
the main point.

- Keep bullet lists short; no more than about 5. If more items are needed
chunk the items under two or more sub-headers. ( This advice is not new: The
"Rule of Seven" was published in the Journal of Psychology in 1956.)

- Keep line lengths short - from 50 to 60 letters and spaces. (Ref. 1, pp.
24-29) Perhaps use two column layout. The research shows that people read long
lines more slowly and sometimes lose their place and miss the next line. If
the lines are short, readers are even willing to put up with long paragraphs
(but short ones are far better).

Later today, we plan to show a before-and-after example of an instruction.
The inital instruction is text only, the revision includes simple graphics and
simpler text.

Let us know if this is of help.

Ceci and Len


As a health educator, illustrations and photographs in any format can
add value to understanding. But I've found that what's often missed is
the essential need for human interaction. Materials cannot replace the
value of a person taking even 1 minute to explain and teach. Materials
are a great place for mutual understanding, and a health provider,
educator, or even a family member who takes a minute to explain how to
interpret the information can make all the difference in understanding.
When I work on creating materials, I try to think about their
distribution and incorporate messages targeting the distributors that
flyers, resource guides, wesbsites, bookmarks, etc aren't just for
handing out. They are an opportunity to start a conversation, to start a
"learner" on the right foot from the beginning.


Megan Sety

Public Health - Seattle & King County

Environmental Health Services Division

Tacoma Smelter Plume Project


Dear list,

Here is an example of the conversion of an instruction in dense text to an instruction with simple stick figure visuals. The instruction with visuals is a DRAFT that might be tested with a sample of the target audience and then given to an illustrator/editor to turn into the finished product - a hand out page, a web page, or read on the radio.

(Julie, I am not sure if the plain text format will allow the two pictures included below or not. So I'll send it first without calling for Plain Text. Please advise.)

Background: This is only one of many instruction pieces that a group of 18 volunteers prepared for government agencies trying to help Katrina victims deal with health and safety problems right after the hurricane. The problems were immediate, so the turn around time to develop the revised instructions was less than 24 hours. (In 4 hours for the example below.) In some cases, the revised information was available to hurricane victims within 2 days.

The original instruction was for people in their homes after the hurricane hit, and then for these people as they later returned to their damaged homes. (See Figure 1 below)

Comments on the original instruction:

1. Readability level of the text is approx 11th grade. Two grade levels above that of the average adult American. And under stress, reading skills and desire to read drop further.
2. The title misses the key point - this is a crisis. "How to deal with Electric and gas utilities" sounds like calling about your utility bill.
3. This 8 line paragraph presents 18 facts and actions - all of them important. But the text is without a break to absorb the information. And the research tells us that 18 is far to many to remember at one reading..
4. The text assumes that people know where their gas valve is located, and what the turn-off valve looks like. Few do.
5. The bottom line: This instruction will be of little or no help to people in crisis.

Comments on the revision:(Figure 2 below)

1. A new title: "Hurricane or flood: What to do about gas and electric."
2. .The instruction was divided into two parts: 1)Before you leave home, 2) Returning.
There is less urgency for the second part, so put that last.
3. Simple visuals were added showing the action (behaviors) to be taken.
4. Action captions were given to each visual.
5. Bullet text below 5th grade readability level. Short sentences that focus on behaviors (actions).

Could you do something like this with one of your instructions?

best wishes,

Ceci and Len

Figure 1. Orig. Text

Figure 2. Revised and including visuals.


Dear list,

Megan Sety of Seattle brought up a way to enhance the effectiveness of
health care (and other) instructions - make the instruction interactive by having
a person help the reader understand. If at all possible, have a person help
the reader by pointing out the key information, and asking them to convert
your (brochure) words into their words. When a patient can do this, they

A parallel idea is to build interaction into the instruction itself. Ask a
question; include boxes to check, ask how the reader will change, or adopt
behaviors, select from several pictures, make a list (include blank lines for
the reader to write in), etc.

With interaction we are involved, we are excited, we learn, we remember.
Thanks for calling this to our attention.

Len and Ceci


To Dr. Doak's point below, the US Administration on Aging has a large multi-media photo gallery of older adults engaged in a variety of activities at:

Also, also we took our own digital photographs for a nutrition and physical activity campaign for older adults at local senior centers. The main cost was staff time, since we used our own talent.

Kay Loughrey

US Administration on Aging.


Both Megan and Susan have commented on the importance of including one to
one contact and personalized explanations of pictures and written
materials. I think this is a very important point. Interestingly, I have
not read this idea before - but that probably is a reflection of my limited
exposure to the field - which is mainly the research side. It is an
important idea that should be researched. I think that it is very likely
that personal explanation will have a marked effect on some patients'
comprehension and behaviors. It would be a simple study to design: text
plus pictures versus text plus pictures plus personalized explanations. I
suspect that the results will be complex - greater effects on certain
populations and certain topics.

I also appreciated the enthusiastic comments from several people on photo
novels. I share their expectation that photo novels can be very effective
in changing behavior - but, as a researcher, this is a hypothesis rather
than an established fact. As I mentioned in an earlier message, we could
not find rigorously controlled studies to prove it. I very much hope that
the people who use these techniques will carry out the research that is needed.

I am leaving on at trip tomorrow morning - returning on January 22. I look
forward to reading more messages on this topic when I return and will add
my thoughts as well. Thank you for allowing me to participate - this has
been a very stimulating and enjoyable project.

All the best,



Thanks, Megan, for addressing the "human connection" and all who agreed.
I do think that all of the visuals we have been discussing have always
meant to be passed on in the context of interaction with a health
provider or educator, but the point is worth reinforcing. And it
reminded me of another message that Len and Ceci Doak sent to the list
last summer, which dealt with spoken communication between physicians
and patients during visits, and how to expand the one-on-one teaching
time without taking up more of the physician's time. Here is an excerpt
from that message:

"We would like to share with you the way that one clinic addresses these
problems. This large free clinic recognizes the communication - time
problem, and has partitioned the process of patient communication. The
examining doctor
provides the patient with the most critical information and explains its
importance to the patient. The patient returns to the waiting room and
then is called for additional discussions with a health care coordinator
who has the patient's medical record with the latest comments from the
doctor. Communication methods involve teach-back, demos and "what if"

One great example of a creative way to enhance patient teaching is the
"Baby Basics Prenatal Health Literacy Program", which is built around a
book with pictures and simple text. The patient keeps the book and
brings it into appointments, the doctor or midwife usess it to reference
answers to questions (pointing to pictures and noting page numbers), and
health educators use it for patient teaching while they are waiting for
their appointments. See the following link for a description and link to
the website.

Any other examples out there of ways to be creative about about
combining human interaction with good pictorial-based materials?


Julie McKinney

Discussion List Moderator


It has been great to read everyones questions, suggestions, research etc. It
certainly makes us feel like we are in good company --developing materials
using visuals. We have been been working for the past several years
designing Medication Instruction and Log Sheets for parents, specific to the
medicine that is being prescribed for their children as part of our Health
Education Project ( H.E.L.P.) at Bellevue Hospital's pediatric clinic.
These bilingual (English/Spanish), low literacy materials, use plain
language and pictures (pictograms) to explain how medications should be
given and includes a log sheet to make it easy for parents to keep track of
dosing. The comments of the Doaks and Peter Houts fit with our

a.. Our patient population is very diverse--piloting new pictograms to
learn how different individuals and cultural groups interpret them is
important to our work and our waiting room is the best place to get
reactions. Parents really feel good about helping us and are eager to share
their opinions, especially "one to one".

b.. In addition to feedback from the "end user", having input from
different disciplines has been very enriching--pediatricians, pharmacists
and health educators each have different but important suggestions.

c.. We found our graphic designer right in the clinic! She is a member of
the Child Life Services --her previous training and her sensitivity to the
needs of the population we serve has been invaluable. Since she worked part-
time, we were able to include additional hours for her to work with us as
part of grant funding. As an added bonus, she has the 'patience of a saint'
as we change and improve our materials.

d.. We have found that in complicated medication protocols, photographs of
medications are more helpful than illustrations alone and have developed
Asthma Instruction Sheets using this model.

e.. Megan's comments about "human interactions" is important. Volunteers
and staff review and discuss the medication instruction sheets and logs with
parents as they wait to see their pediatrican as part of a larger general
"conversation" about giving medicine to children. Our hope is that many of
the parents will already be familiar with the materials and how to use them
when they get a prescription and these materials from their doctor.

f.. Studying the efficacy of our materials has been a time consuming but
fascinating process that has lead to significant changes in our design.
Initially we did a Quality Improvement Project and then a randomized control
study of liquid medication materials on 146 parents seen in Pediatric
Emergency Service. The results of the study are promising: parents who
received the sheets demonstrated increased accuracy in dosing their child's
medication as well as improved adherence to the medication schedule. For
"as needed" medications, caregivers who received the medication sheets dosed
accurately 86.7% of the time compared to 60.5% of the parents who did not
receive the sheets. For "daily dose" medications, 95.7% of caregivers who
received the sheets dosed accurately compared to 64.3% who did not receive
the instruction sheets. In addition, parents using the sheets had improved
adherence to their medications schedule (100% vs. 69.0%).
We hope to have these materials available by early summer to every parent
who gets a prescription in our clinic. The discussions of the past week
have been very helpful as we move forward.

Linda van Schaick MS Ed

Shonna Yin, MD


I have been reading this listserve for some time now but without
comment. It's been a wealth of great information and my next comment is
in no way meant to minimize all of our efforts in developing good,
clear, plain language health information. However, Megan's point is
worth underscoring. Having been a patient educator at Packard
Children's Hospital at Stanford (for almost 20 years) and now working
with the CA State Library, my experience has led me to believe that the
importance of the personal interaction cannot be emphasized enough.

We are all being pressured to reduce everything to the 60 second "sound
or print bite" -- even if we could succeed in doing this (which is
doubtful), that is not a guarantee that we will be able to impact
behaviors. And ultimately that is what has to change since most health
strategies (both preventative and curative) require a chance in habits
and/or behaviors. We could paper the world with information -- but
information is NOT what motivates behavior change. So I would encourage
us, in addition, to working to create effective health education
materials to also continue to explore the "people skills" that all of us
need (health and non-health professionals alike) to effectively bridge
the gap between information and behavior change.

Suzanne Flint, Library Programs Consultant

Library Development Services

California State Library


Hi Everyone,

In case you were not able to open the PDF attachments, here are some
links to online access to th following PDFs. The article by the Doaks
and Peter Houts will also be available next week.

Using pictures to improve health communication

Presentation by Peter Houts, PhD

Use of pictorials in medication instructions: A review of the literature

by Marra G. Katz, Sunil Kripalani, and Barry D. Weiss

I will also compile a list of the other great resources mentioned during
this discussion, and send it out.

All the best,



Dear list,

We hope that the focus this week on more effective use of visuals has been as
stimulating for you as it has been for us. Your inputs have helped shape and
frame the discussion and for us it has been most exciting. Thank you for
this opportunity to share knowledge and experiences.

We'd like to summarize by highlighting a few topics again and then pull
thoughts together in the context of "Suitability of Assessment of Materials" from
our book, Teaching Patients with Low Literacy Skills.

Thinking Visually:

Let's briefly review the problem of "how to think visually". One of the most
effective approaches is to get in the mood by reviewing two or three
examples: start with Peter Houts' Eldercare material and as you go through the pages,
some ideas of how you can use this approach will come to you. There are a
number of gov't pubs that have good examples. In the environmental field, "The
Right to Understand:Linking Literacy to Health and Safety Training" published
by Labor Occupational Health Program, Univ. of Calif, Berkeley, 1994,
illustrates and explains why stylized images are less useful than familiar images.

We are impressed with the focus now being given visuals by the Am. Public
Health Assoc. The January issue of the monthly journal arrived yesterday, and lo
and behold, the cover is a cartoon of the topic "disentangling health
disparities through national surveys". The editor says "expect to see more cartoons
in our pages and on our website as we move judiciously forward with new tools
and diverse media ..."

Perhaps this focus by a highly respected national journal will support your
interests and help your supervisors and administrators realize the value of
visuals as "new tools". If your supervisor is still skeptical about using
visuals, consider creating two draft versions of a brief instruction. Test each
with a small group of patients, and show that your results in improved patient
recall and understanding are similar to other research finding - and could
improve your organization's health care effectiveness.

Suitability factors for visuals:

In pulling together the various elements of making visuals work for you, we
offer the following summary drawn from "Suitability Assessment of Materials"
(found in Chapter 4 of our book):

  1. Graphics
    1. cover is friendly, attracts attention, clearly portrays the
      purpose of the instruction to the intended audience
    2. simple line drawings can promote realism without distracting
      details. (Visuals are accepted and remembered
      better when they
      portray what is familiar and easily recognized.)
    3. relevance of illustration is key to comprehension.
    4. details such as room background, elaborate borders, unneeed
      color are not included.

  2. captions can quickly tell the reader what the graphic is all
    and where to focus within the graphic.
  • Layout: consider these factors:
    1. Illustrations are on the same page near the related text
    2. layout and sequence of information are consistent, making
      easy for the reader to predict the flow of information
    3. cuing devices (boxes, arrows, etc) direct attention to
      key points
    4. white space reduces clutter and gives "breathing room"
    5. color supports and is not distracting; color "codes" are
      necessary to understand the message
    6. high contrast between type and color of paper; no
      images or logos are used.
    7. non-gloss or low gloss surface. (Gloss reflects light
      and slows
  • Typography: this affects reading speed
    1. text type is uppercase and lowercase serif, if possible
    2. type size is at least 12 point
    3. typographic cues (bold, size, color) emphasize key points
    4. no ALL CAPS for long headers or running text; they destroy
      for all readers, especially, in deciphering letters
    5. lists need to be partitioned into small "chunks"
  • Interaction included in text and/or graphic
  • There are other points which affect comprehension but this will be a good
    starting point to reach our goals of comprehension and compliance.

    Thank you so much; We and Peter invite your comments and suggestions and
    ideas for further discussion. ( Peter may wish to add his own summary when he
    reutruns from vacation in about 2 weeks.)

    Ceci and Len Doak


    Hi Everyone,

    I want to thank you all for an excellent practical discussion about
    using pictures for health education! And I especially thank Len and Ceci
    Doak and Dr. Peter Houts for sharing their experience, research review,
    analysis and insight in order to inform our efforts to use pictures and
    visuals most effectively in health education materials and clinical

    Even though the scheduled discussion ends today, I hope that we can
    continue to discuss this topic and share resources, stories of work that
    we are doing, and other information.

    Again, thanks to all! Have a great long weekend.

    All the best,


    Julie McKinney

    Discussion List Moderator

    World Education/NCSALL

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