By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting
On Call Magazine, May 8, 2008

When Bill Smith, EdD, was working as a Peace Corps volunteer in Colombia, he and colleagues faced the challenge of educating people in a rural village about malaria. One teaching strategy they used was to project pictures of mosquitoes on a screen in order to emphasize how these insects can cause disease. In the discussion that followed, though, one villager said there is no problem where she lives. When Smith asked why, the woman responded, “Our mosquitoes aren’t that big.”

The lesson that Smith took from this experience is that people don’t visualize things the same way. “In this instance,” he says, “the villagers didn’t have the visual literacy to know that a picture of a small creature was blown up.” Now, as executive vice president of AED — the Academy for Educational Development — in Washington, D.C., Smith and a team of 200 professionals build on this lesson to help improve education, health, civil society, and economic development in the U.S. and countries around the world.

How information is stored determines how new information is received

Smith and I recently discussed how visual literacy affects health understanding. People everywhere, he says, put information in “mental boxes” of understanding. No matter where they live or what culture they are from, people use these boxes to make sense of unfamiliar concepts, words, and pictures. According to Smith, “A major part of health literacy is understanding or figuring out the boxes where people put information.”

Smith talks about working with mothers in Honduras who could not read. The task was to teach them how to make a mixture to intervene with diarrhea. The first challenge was what to call this mixture since the term “medicine” didn’t make sense to these mothers in this context. To them, medicine is something that is only given by the teaspoons or other small quantities. “But ‘tonic’ they understood because they drink a lot of it,” Smith says. So the team decided to refer to this mixture as “tonic for diarrhea.”

To make this “tonic” correctly, women needed to mix a pre-measured packet of salt and sugar with 1 liter of water. This had to be done in the correct proportion. Too little water and the mixture would be overly concentrated and the child could die; too much water and the mixture would be so diluted as to not be effective.

Following principles of user-friendly communication, Smith’s team asked local artists to draw visual instructions which he then tested with the intended audience. To his surprise, the mothers looked at the instructions but did not follow them. Instead, they mixed the packet with a glassful of water, not a liter. When asked why, the mothers said they thought the pictures were just decorations. As the AED team quickly learned, these women were unfamiliar with the concept of visual instruction.

To better explain what to do, Smith and colleagues ran a radio campaign about these instructions. “Look at the pictures and they’ll tell you how much water to mix in,” said the radio announcer. This verbal explanation added to the locally-drawn illustrations solved the problem. Smith reports there was increased compliance and reduced deaths from diarrhea as a result.

Being creative is a key to meeting educational challenges

Regardless of your setting or population, Smith offers lessons all healthcare providers can use to meet teaching challenges in creative ways.

Teach what visuals mean. Smith compares pictures to Egyptian hieroglyphics, saying that learning what they mean can be as hard as reading and writing. “It is not sufficient to just create visuals you think are intuitively understandable,” says Smith. He explains that people will come up with their own interpretations if they do not understand the meaning of certain words or pictures. This may or may not be the meaning you intended.

Potential misinterpretation can also apply to visual symbols (non-human representations). An example is a circle with a line through it to convey the concept, “Do not do this.” Even though this symbol is widely used, it may not be universally understood. For example, people may not necessarily interpret a picture of beer bottles with a circle around it and line through it to mean, “Do not take with alcohol.” For human and non-human representations alike, always make sure that context is such that the intended audience will be able to understand the messages you are trying to convey.

Use line drawings rather than photographs. Worldwide, Smith has found that people often find photographs distracting because of too much visual information. They may miss key points by focusing instead on clothes that people in the photograph are wearing or objects they see in the background. Smith finds that, almost always, simply drawn illustrations emphasizing a limited number of key points work best.

Start with already drawn illustrations. Smith recommends using “tear-off” pads with key visual information already drawn on them, especially when providers are not skilled artists. An example is the tear-off sheet, For the Patient: What You Must Know About Medication developed by Literacy Suffolk, Inc. in New York.

This tear-off sheet includes drawings of four clocks, each without hour or minute hands. Providers need only add the clock hands to indicate times patients should take a certain medication. This one-page illustrated form is designed for use by prescribing providers to help ensure medication compliance by patients who have limited literacy skills.

Create and combine teaching techniques. People who cannot read or have only limited literacy skills generally have excellent “oral memories,” says Smith. This means that they are not likely to forget or confuse details once they hear them. The power of oral memory is one reason Smith advocates using radio to teach and reinforce health messages. In the U.S. as well as elsewhere, people often listen to the radio in the evening. “We underestimate the power of radio in poor communities in America,” he says.

Beyond pictures and radio, the range of effective teaching tools is limited only by imagination and resources. Smith talks about other creative strategies he has used with specific populations. For instance, in the West African nation of Gambia, he again needed to teach about mixing salt, sugar, and water to help with diarrhea. Mothers needed to correctly measure all the ingredients since this community could not afford pre-mixed packets. Because they had no teaspoons to measure the ingredients, Smith taught about using the proper amount of salt and sugar in terms of bottle caps — the only consistent measuring tools available.

The team also used colored boxes around illustrations to organize and present the step-by-step instructions rather than using the unfamiliar terms “left” and “right.” To make sure the mothers knew what to do, Smith and colleagues then held “village mixing contests” in which women helped one another make these mixtures correctly.

This project met with remarkable success. “The number of mothers who mixed properly was amazing,” says Smith. He credits combining several teaching techniques, all of which are consistent with the way local people understand and interpret information. Indeed, across the U.S. as well as around the world, people learn health messages best when they can fit them inside their mental boxes of understanding.

Ways to learn more:

Bill Smith, Ed.D. is Executive Vice President of AED, based in Washington, D.C. You can reach him by email at bsmith@aed.org and learn more about AED on the Web.

Carstens A, Maes A, Gangla-Birir L. 2006. “Understanding visuals in HIV/AIDS education in South Africa: differences between literate and low-literate audiences.” African Journal of AIDS Research, 5(3);221-232.

Literacy Suffolk, Inc. is an accredited ProLiteracy affiliate. You can learn more at Literacysuffolk.org.