HLOL Podcast Transcripts

Health Literacy

Visual Metaphors: When Words Alone Are Not Enough (HLOL #178)

Helen Osborne: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and your host of this podcast series, Health Literacy Out Loud. In these podcasts, you get to listen in on my conversations with some really remarkable people.

Today, I’m talking with Dr. Alex Thomas and Gary Ashwal, who are co-founders of Booster Shot Media.

Alex is a board-certified pediatric allergist and immunologist and also a cartoonist and illustrator with more than 20 years of experience.

Gary is a health communication specialist and a multimedia producer of healthcare content.

With 16 years of a creative partnership, Alex and Gary apply their combined experience to produce comic books, animation and other visual projects to teach people of all ages about complex health topics.

I met Gary when I was at a health literacy conference. We quickly realized that we share an appreciation of using creative and artful ways to communicate health messages. I thought our conversation should continue, and you, the listeners ofHealth Literacy Out Loud, might want to listen in.

Welcome, Alex and Gary.

Alex Thomas: Thank you for having us.

Gary Ashwal: Thank you. We’re excited to be here.

Helen Osborne: Between the two of you, I really want to hear more about the work you’re doing, especially why and how you use comics, animation and whiteboards to give important health messages.

Gary Ashwal: Sure. Thank you. Helen, this is Gary, for everyone to have my voice.

Alex and I, just like you and I, Helen, connected over our love and interest in using creative materials along with health education, health communication and health literacy. That is the same reason that Alex and I have been working together for so many years.

We actually began with a creative partnership, doing work completely unrelated to health. A lot of work that involved drawing, performance and visuals.

Then later on, once we both got our higher degrees, Alex in medicine and mine in health communication, we started figuring out that we could combine all of our different areas into working together to create materials that are both really creatively exciting and making an impact and actually delivering information in a way people are going to want to be engaged with it, remember it and be able to act upon it.

Helen Osborne: That’s neat. You started with that creative, artistic flair, and then added the professionalism in medicine and health communication after that. That’s a neat story. I’ve got my own. Sometime, we’ll share it.

Alex Thomas: We started in college as a theater company. That’s how we first started working together. Then the need really came for me when I was an intern in pediatrics, working at a children’s hospital, where I was seeing that a lot of children were being admitted and readmitted with asthma issues.

As I got to know these kids on their multiple visits, I realized that a lot of it had to do with an inadequate education about their medications. Looking at what the hospital had to offer at the time, I realized that there was a lot of room to grow.

That’s when I started thinking about maybe I could create something like this. But I didn’t really have the language or the understanding of the way to create something at an appropriate health literacy level for the certain age group. That’s when I realized that Gary was studying this at the time.

Then we started working together way back then, really to address a real need that I saw clinically in my experience.

Helen Osborne: I’ve been a big proponent for so long about communicating in whatever ways work. Sometimes I get people looking at me like “Really? You could use puppets, song, drawings or something?” There might be a little bit of pushback. I think it takes a dose of courage to do things in a nontraditional way. Does it?

Gary Ashwal: I think, at first, it can be difficult maybe for some people to understand why we might be using materials that are unfamiliar to them.

At the same time, there is often an incredible response to some of the materials we have, where people do see the materials and get it right away. Where they say, “I’ve been looking for something like this. Everything we have is so boring, too complicated or not visual enough.”

We get both reactions, but what we have been able to do with a lot of our projects is actually have them evaluated. When we have actual patient feedback throughout the process or when we have studies that show actual knowledge increase that can be retained over time, that gets a lot of people on board who might have been initially skeptical.

Helen Osborne: It’s not just that it seemed like a good idea and a really cool thing to do. It really works.

I keep saying “it.” I know you communicate in a lot of ways, using various elements of visuals, whether they’re animated or on a whiteboard or a cartoon that people might be more familiar with. I’m hoping we’ll weave in some examples of some projects that you’re doing. But I want to be looking at a bigger thread.

When we were planning this podcast and I was looking over some of your materials, I saw somewhere that term, or maybe we talked about it, called “visual metaphors.”

That seemed to be an underlying theme about all the different ways you’re communicating health messages. That term, a visual metaphor, seemed to resonate with all of us.

For listeners, could you share what you mean by that term, that I hadn’t otherwise heard?

Alex Thomas: Sure. I think that early on when we started creating educational materials, we realized that using metaphors to express potentially complex medical concepts was a way of avoiding the materials appearing too didactic or boring for the patient, whether they’re an adult or a child.

Helen Osborne: I’m going to interrupt you right there, because by a metaphor, as I understand metaphors, you’re comparing something unfamiliar to something well known to that person. Is that correct?

Alex Thomas: Exactly right. Yes. For example, in our first project, Iggy and the Inhalers, this was a comic book to teach kids about not only the pathophysiology of asthma, but the mechanism of action of the inhalers that they take.

This was really to address the problem that I was seeing early on in my training. The materials that were out there were treating asthma medications with a broad brush, as a magical thing to make your symptoms better.

That is not really helping the patients understand when and how they should use their different medications that often look identical but should be used in completely different ways.

What we wanted to do was to create a metaphor that would connect the mechanism of action of one inhaler to a character that a child might be familiar with, using tropes and characteristics of well-known characters, for example.

To give a specific example, we were trying to differentiate between a bronchodilator, which is a quick-acting, rescue type of medication, versus an inhaled corticosteroid, which is a daily anti-inflammatory medication that is slow acting but needs to be used every day regardless of how you’re feeling.

To do that, we created Broncho the Bronchodilator as this embodiment of the medication that’s a quick-acting inhaler. He was a fast-talking cowboy with a lasso that would loosen the muscle bands outside of the airway that cause bronchoconstriction.

Helen Osborne: Neat.

Alex Thomas: To contrast that, we had Coltron the Controller, who embodied the inhaled corticosteroid. He was a larger, deep-voiced, slow-moving but powerful-appearing robot who had a fire-extinguisher arm that would shoot the inside of the airway to decrease inflammation, as if he was putting out a fire.

That was a metaphor that we used to illustrate to the kids that these are two different medications that have very different characteristics. But if you just understand the story and know the characters, you’ll more intuitively understand your medications without feeling that you’re memorizing facts on a sheet of paper.

Helen Osborne: From your perspective, because you see kids all the time who have asthma, that’s what you do, did you see that they get it when they see this?

Alex Thomas: Yes. I think that early on we were amazed, because as Gary mentioned, we did a lot of formative evaluation as we were creating this.

One of the things we were lucky enough to do was to have the asthma camp in Madison, Wisconsin, where I work, use our materials periodically as we were developing them.

As part of the asthma camp, at the end of the day, I would talk to the kids and have them fill out pre- and post-camp surveys about asthma notes.

It was astonishing just seeing an 8-year-old write down the explicit mechanism of action of a bronchodilator, which was a fact that I personally didn’t learn until I was in medical school. They were retaining it, and that was really important for us to understand, that it was actually working.

Helen Osborne: Could you move them away from the robot and the cowboy into the real terms? If they’re not treated by you, and they’re treated by somebody else, talking about a cowboy has no meaning.

Alex Thomas: That’s part of how the names work. It’s Broncho the Bronchodilator, and throughout the comic, he emphasizes that he’s a quick reliever, using the terminology of what that inhaler would be called.

Helen Osborne: You’re teaching at the same time.

Alex Thomas: Absolutely. We have a glossary of terms in the comic as well. I think that, for us, going back to getting that support from people who are not familiar with using comics or other types of nontraditional formats of education, part of getting that buy-in is to make sure that what we’re creating is medically and scientifically accurate and up to date.

We’ve revised Iggy multiple times over the years to make sure that we’re keeping up to date with the most common and accepted terminology used by asthma educators so that when they look at their materials and evaluate it, they know that the content is still appropriate, even if the format is a little bit more nontraditional.

Helen Osborne: That’s great. I actually have taken a look at the comic book. I was really impressed. We’ll have a link to Iggy and the Inhalerson your Health Literacy Out Loudweb page.

Thank you for that, Alex. Gary, I’m going to ask you to do something similar, but maybe it’s harder. Alex is writing, or together you’re creating comics for kids. Is there another example of how you might use visual metaphors, not for kids, for adults, on a totally different topic that I can’t even imagine would lend itself to such a visual format?

Gary Ashwal: Yes. We’ve actually had the good fortune to partner with a number of different research groups, where we’re creating materials, mostly whiteboard videos, that are being used to communicate with an adult audience.

Helen Osborne: A whiteboard video, I’ve seen some on YouTube or I’ve seen some in presentations. There’s a white background, there’s someone drawing some images and then they go away. It’s pretty fast-paced, right? Then it moves on, information after information?

Gary Ashwal: Exactly. What’s special about the whiteboard videos is that they give you the feeling of someone drawing some visuals to explain something to you while you hear a voice explaining those things.

Even though maybe sometimes it can feel like it’s fast-paced if you’re looking at it, the idea is that what you’re hearing and what you’re seeing is very lined up.

The better videos are the ones that give you that just-in-time feeling. As you’re being shown something, the person who is doing the narration is saying that thing, so it’s unfolding experience. That can allow for communicating some pretty complicated or abstract ideas.

With the example of these research groups, one of the things that we’ve needed to explain, for example, is explaining how medical research works when they’re comparing different medications. One of the aspects of that is explaining how randomization works.

Helen Osborne: That’s certainly not a kid’s concept.

Gary Ashwal: Not necessarily. This is something that we were explaining to adults and we needed some way to convey to people this abstract idea.

In one of the projects, one of the ways that we ended up doing this was using the concept and a visual of a gumball machine. You could see a gumball machine with many different colored gumballs.

Helen Osborne: That’s where you put a coin in and you get a gumball.

Gary Ashwal: Exactly. We’re using the gumball visual metaphor. We show someone putting a coin in and then getting a randomly colored gumball out of the machine, so that no matter what you get, you get a gumball. You just don’t know what color it’s going to be.

Then we do the same visual and we show the medicine coming out of the gumball machine. You can know that you might get a random medicine. You don’t get to choose. It’s just we know that we need to give you a medicine, so we trigger this gumball machine and you get a medicine. All the medicines have good qualities, but we’re randomizing them to the different people.

Helen Osborne: Wow. I’m really impressed by not only the creativity of how you’re doing this, but also how you’re explaining it just by words on this podcast. I have a clearer picture in my mind, even though I’m not looking at it right now, of these visual metaphors.

For listeners, they’re perhaps not great artists like both of you or necessarily trained in some aspect of medicine or health communication. But they care. We all care about doing things a little bit better today than we did yesterday.

What tips would you share about how people can incorporate the visual and the creative in their health communication?

Alex Thomas: I think that the important thing about the use of visual metaphors is first finding a common thread that the patient or the person you’re speaking with can relate to.

For example, with some of our work, we think about the popular things that kids are excited about these days, or a concept like a gumball machine. That’s something that you’re pretty confident the patient is familiar with. I think that having that common ground to start with is the jumping-off point.

Helen Osborne: Good. Thanks for that. I actually did a podcast a while ago and wrote an article about creating metaphors. It wasn’t until I met both of you that I thought about visual metaphors. I’ll link to my article about metaphors.

Any other tips?

Gary Ashwal: Yes. One of the other tricky parts with using a visual metaphor is that a visual can communicate a lot of meaning that’s even subtle.

One of the things that we often get to do is we take the ideas of the metaphors that we’re thinking about, we create some visuals, some sketches or some more finished artwork, and we’re able to share that with people who are maybe in the target audience, say, a patient advisory committee on a research project.

That is always an important part of a process that I feel strongly about building in when you’re taking this approach. In those conversations, you’re going to learn a lot about what the metaphor meaning is and what the visual meaning is that you might not have considered.

As an example, we were doing another research project. We were explaining biobanks to patients, which is when they take blood samples or medical information and can store it in a centralized repository, to be used in research in the future.

What we did was we used a metaphor of a library for that project. We also were trying to convey things about security and oversight.

We had these metaphors of guard dogs guarding the library. We also had these metaphors of referees making calls about who might be allowed to actually access the library.

Once we got into the focus group with the patients and we were getting representative patients from lots of different cultural groups, we heard a lot of negative feedback from certain groups about certain metaphors we were using that weren’t necessarily anticipated.

Then we went back and we revised our metaphors, basically, to make sure that we were not triggering some kind of extra reaction that was counterproductive.

Helen Osborne: It sounds like a health literacy principle that many of us abide by, about get feedback. Do the teach-back or get feedback from those representing your intended audience. It sounds like you can learn what works and what doesn’t work in that way.

Looking ahead, do you see that this a kind of strategy that everyday folks can include somehow in their work?

Gary Ashwal: Yes. I think that it’s available to anyone, even if you’re not necessarily a visual artist. There’s a huge number of resources online where there are these stock photography, stock illustrations, stock icons even, where you can browse and peruse and pull things together. Some are available for free, some you license and that kind of thing. You can use those just as images that help get a conversation started.

You just need to use the metaphor as a starting point when you’re trying to explain something. Then you can move away from the metaphor and start getting into the actual explanation. It gives someone something to anchor onto.

Helen Osborne: It’s just that one more way of using visuals for learning and teaching. Not everybody learns all ways. It sounds like let’s add that to our toolbox of possibilities.

Alex Thomas: There is one point I just wanted to make at the end of this conversation, which is that sometimes a metaphor is not the right way to go.

The point is that the use of a visual metaphor is not in and of itself, but it’s a means to achieve a more streamlined way of educating a patient more meaningfully.

There are times where actually being very literal and straightforward in your visual representation of something is actually the quickest way to get to that point.

I think that the visual metaphor by far is a great tool. But you should also be able to admit when it is not the most helpful way of communicating a point.

Sometimes Gary and I will get to a point where we are working on a metaphor and then we just realize, “Actually, it’s more clear if we just explain what this is as clearly as we can and abandon the metaphor.” That’s something to also keep in mind when you’re working with visual metaphors.

Helen Osborne: Thanks. I had an image, as you were talking about that, of exactly a toolbox, like we have in our house. Sometimes you need this tool or that tool, or it’s the wrong size or maybe just try something else that’s not even in the toolbox.

Thank you so much, both of you, for sharing all your experiences, your enthusiasm and your talents about communicating visually and using visual metaphors.

How can people get a glimpse of what you’re doing?

Gary Ashwal: We have a website, which is www.BoosterShotMedia.com, where we put up all of our different projects once we complete them. You can find links to watch some of the videos or read some of the comics.

That’s really the best way to see the wide range of the times where we use visual metaphors and the times where we’ve certainly decided, “Let’s use a different type of visual strategy to communicate this particular project.”

Helen Osborne: That’s great. I really like hanging around your website. Thank you both so much for being guests on Health Literacy Out Loud.

Alex Thomas: Thank you so much for having us.

Gary Ashwal: Thanks, Helen. It was really fun talking to you.

Helen Osborne: As we just heard from Gary Ashwal and Alex Thomas, it’s important to communicate visually as well as in words. But doing so isn’t always easy.

For help clearly communicating your health message, please visit my Health Literacy Consulting website at www.HealthLiteracy.com. While you are there, please sign up for the free monthly e-newsletter, What’s New in Health Literacy Consulting.

New Health Literacy Out Loudpodcasts come out every few weeks. Subscribe for free to hear them all. You can find us on iTunes, Stitcher Radio. Google Play, and the Health Literacy Out Loudwebsite, www.HealthLiteracyOutLoud.org.

Did you like this podcast? Even better, did you learn something new? I sure hope so. If you did, tell your colleagues and tell your friends. Together, let’s tell the whole world why health literacy matters.

Until next time, I’m Helen Osborne.

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"As an instructional designer in the Biotech industry, I find Health Literacy Out Loud podcasts extremely valuable! With such a conversational flow, I feel involved in the conversation of each episode. My favorites are about education, education technology, and instruction design as they connect to health literacy. The other episodes, however, do not disappoint. Each presents engaging and new material, diverse perspectives, and relatable stories to the life and work of health professionals.“

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