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

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

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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 helping.

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; 63(23):2391-2397.

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

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 effective?

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 low-to-medium 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% screen). I've done it often and these techniques field test well with limited readers.

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 topic 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 levels.
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 understand.

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" questions."

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 observations:

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. Nonessential
    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 about, 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 it 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 not necessary to understand the message
    6. high contrast between type and color of paper; no "shadow" images or logos are used.
    7. non-gloss or low gloss surface. (Gloss reflects light and slows reading)
  • 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 cues 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 encounters.

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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