Article from the Boston Globe’s On Call Magazine, November 1999

By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting

What’s in a picture? When your object is to get across messages your audience need for their health, the answer is lots.

Healthcare information is traditionally communicated through the written and spoken word. But these are not the only, or always the best, ways to present important information. People learn in a variety of ways: by hearing, seeing, reading, and doing. Some individuals prefer one learning method to another, and sometimes a combination of ways is most effective. When people have special learning needs, such as low literacy skills, cognitive disabilities, or increased stress, or when they do not speak English as a primary language, it may be especially important to use visual teaching tools.

Graphics, or visual representations, are effective ways to convey complex concepts, using them to either supplement or substitute for, the written word. They can be presented in a wide variety of ways, including brochures, posters, flip charts, cutouts on flannel boards, blackboard drawings, slides, filmstrips, and overheads.

Pictographs Convey a Lot of Information Quickly

Pictographs are a special type of graphics. They are simple drawings that represent ideas, and they can help a person grasp, understand, and remember medical information quickly. Pictographs have a long history, dating back to cave-wall paintings and renaissance stain glass windows. Today, road signs are a common example of pictographs. A sign with a simple picture of a school bus, for example, conveys the more complex message not only that a school bus is likely to go down the, but also that drivers should be alert to the possibility that children might walk across the road.

“Pictographs can also be cues to help people remember spoken information,” says Peter Houts, PhD, professor emeritus at Pennsylvania State University, College of Medicine, and research associate at the Johns Hopkins Oncology Center. Houts is currently researching the use of pictographs to help cancer patients and AIDS patients who read below a fifth grade level remember medical instructions. Using simple drawings of patients, doctors, nurses, and family members, Houts has created a series of pictographs that show low literacy patients and family caregivers how to recognize a medical emergency as well as how to avoid medical emergencies. A sampling of these pictographs can be seen on the Johns Hopkins Oncology Center Web site at www.med.jhu.edu/cancerctr/ptfamsvc.

Houts feels strongly about the value of pictographs in communicating health information, and he recommends that clinicians should use them in their everyday work – especially when working with people who have difficulty reading.

Make Graphics Part of Your Everyday Presentations

Here are some ways to make graphics in general and pictographs in particular a more routine part of your patient communication.

1. Ask, rather than assume, how people like to learn and then have alternatives available to be able to teach in a variety of ways. For example, you should be able to provide smoking cessation information in a range of formats. These include written materials (including easy-to-read and translated booklets and brochures), Web sites, audio and videotapes, physical objects (such as a lung damaged by smoke), discussion and self-help groups, and telephone hot lines. When you make a decision about which teaching tool to use, consider learner preference as well as cost and availability of materials.

2. Use pictures in patient materials that represent a specific action and that are not purely decorative. Some patient education materials have drawings for decoration rather than to show what a person should do. This wastes valuable space that could be turned into an effective teaching tool. The most effective illustrations are of a person doing an action because this tells the viewer what actions he or she should take. Include clear and simply written text to further emphasize what the picture shows.

3. Create and use simple pictographs that do not have unnecessary details. “Effective pictographs are something anybody can do, don’t take very long to draw, and don’t have to be good looking art,” says Houts. Stick figures or doodles are fine to use, and often avoid issues related to gender, culture, and mood. A library of medication-related pictograms that clinicians can download is available at the USP Pharmacopeia web site, www.usp.org.

4. Focus on using concrete pictures rather than abstract symbols. In Hout’s research, he has learned that pictures of people are often preferred to more symbolic images. For example, his test group of low literacy persons stated a preference for a drawing of a person wagging a finger to indicate the concept of “Don’t do this action,” rather than a picture of a circle with a slash through it.

5. Include pictographs on action lists. When you provide step-by-step information showing an entire action sequence, have a drawing next to a verbal explanation of each action item showing the correct way to carry out each step. Later, the drawings will help the patient remember the explanations without having to reread the text. An example of pictographs used to help patients understand instructions and procedures for radiation therapy can be found in the brochure, “Radiotherapy, A Guide for Lung Patients,” published by Bristol-Myers Squibb Oncology, 1997.

6. Draw attention to essential information within a larger drawing or document by highlighting, or drawing circles and arrows. By highlighting and focusing attention on the most important things, you make it easy for a patient to scan material looking for what they need.

7. Give the pictograph to the patient. Encourage patients to take home your doodles and pictographs you draw for them while you are talking to them to serve as a reminder of the clinical discussion. Have paper and pencils available so patients can make their own pictographs to remind them of what you say.

Work with your target audience to develop, test, and improve teaching materials. Make sure your target audience can easily understand the meaning of your pictographs, and be willing to change the drawings according to their feedback. In judging printed materials with graphics, you might ask: “What do you think of when you see this picture? What do you think this picture is telling you to do?”

How to Find Out More:

You can find examples of  pictographs at the following Web sites:

www.med.jhu.edu/cancerctr/ptfamsvc

www.USP.org.

Printed Resources

• Beyond the Brochure: Alternative Approaches to Effective Health Communication. Available from the AMC Cancer Research Center, 1600 Pierce Street, Denver, CO, 80214
• Doak, C., Doak L., and Root J. (1996). Teaching Patients with Low Literacy Skills. J.B. Lippncott Company, Philadelphia.
• Houts P., Bachrach R., Witmer J., Tringali C., Bucher J., Localio R. (1998). “Using pictographs to enhance recall of spoken medical instructions.” Patient Education and Counseling, 35, 83-88.
• Redman, B. (1993) The Process of Patient Education. Mosby-Year Book, Inc. St. Louis.