Helen Osborne: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and author of the book Health Literacy from A to Z: Practical Ways to Communicate Your Health Message. I also produce and host this podcast series, Health Literacy Out Loud.

Today, I’m talking with Mareika Phillips. With more than 10 years of experience, Mareika leads teams at Communicate Health to develop creative design solutions that make health information engaging and accessible.

She believes deeply in design as a universal language, and focuses her work on making designs accessible for everyone regardless of any mental or physical differences.

I’m a big fan of Communicate Health’s weekly newsletter called We heart health literacy. Each newsletter focuses on a specific topic. I was especially intrigued when I read one recently about using pictograms in health materials.

I wanted to know more, so I spoke with Mareika, the head of Communicate Health’s design team. Happily, she agreed to be a guest on Health Literacy Out Loud.

Welcome.

Mareika Phillips: Thank you so much, Helen. I am super excited to be here chatting about pictograms today.

Helen Osborne: Pictograms. I first heard that term in the late 1990s, back when I was fairly new working in health literacy. There was a researcher named Dr. Peter Houts, and he was doing a lot of research on pictograms and their use with people who were diagnosed with cancer or AIDS, and how pictograms could be a great tool for health teaching, especially for people who struggled to read.

That was Peter’s story and journey many years ago. Tell us from your perspective what pictograms are.

Mareika Phillips: That is a great question that has probably a very complicated answer. They can overlap with illustrations and they can overlap with icons, but essentially, a pictogram is a drawing or an image that represents an idea in a simple or literal way.

Helen Osborne: Tell us more of what you mean by simple and what you mean by literal.

Mareika Phillips: What I mean by simple is that the idea is getting across as easily as possible, so with as simple of a scene as possible.

And literal meaning just what you said, Helen, about folks who struggle with reading. We want pictograms to be as legible for folks who have cognitive disabilities or reading disabilities, or are very stressed out at the time, which we all know a lot of folks who are receiving health information are in various emotional states.

Anyone who is having trouble reading at that moment, we want to get the idea across to them in as literal a way as possible.

Helen Osborne: Without using words. Are they the same as icons and pictographs? I know you used illustrations, but are there a whole bunch of different things all called pictograms? Or are they distinct in their own way?

Mareika Phillips: I find those two terms to be interchangeable, pictogram and pictograph. But the overlap between icons and pictograms is not linear. They’re overlapping Venn diagrams. Some icons can sometimes be going into pictogram territory, depending on how simple they get.

I would say the way to distinguish them is the simpler the concept and the simpler the visual representation, the more likely it is to be an icon.

The more complex the idea that you’re trying to represent, the more likely you could categorize it as a pictogram. But it’s on a continuum.

Helen Osborne: You used a lot of visual images, like the Venn diagram and overlapping. I’m going to make you do something that is maybe not natural for you because you’re an artist with drawing. I want you to describe this in words, because our podcast is sound only.

Describe what would be a pictogram and perhaps compare that to an icon so all of us listening, no matter what else we’re doing right now, can picture what you were talking about.

Mareika Phillips: That is a great ask, Helen. I love that.

Something that I would think of as definitely in the pictogram category would be representing a concept like “Keep this medication away from children.”

If you can imagine, that might be a scene where you have a parent or caretaker putting a medication away from a youngster all in one scene. That’s a representation of a very complex scene, so that would be in the pictogram category.

Helen Osborne: My image, and I don’t know if there’s a right one or a wrong one, but I have a picture of a little kid who’s little kid height and a person reaching up and putting it in the medicine cabinet. There are a lot of steps to it. Is that what you’re talking about?

Mareika Phillips: Yes, that is what I mean. It’s just one scene, though. It’s not a lot of steps. Just one scene would be the pictogram.

Helen Osborne: It’s one scene, one moment in time. You’re not saying there are four different ways to keep medication away from kids. You’re just showing one way.

Mareika Phillips: Exactly. Then on the other hand, a very clear representation that would be an icon would be something like a star or a heart that’s allowing you to favorite something on a website, to save it as a favorite. That would be an icon, for sure.

Helen Osborne: Is that like a stop sign or a traffic sign or something?

Mareika Phillips: A traffic sign I would put in the pictogram category, only because the concept is a little bit more complex.

Helen Osborne: All right. Sometimes you have words with pictures.

Mareika Phillips: Yes.

Helen Osborne: Are you talking about pictures only? I’m thinking of a traffic sign, like “Merge,” where you have arrows going whichever way you’re going and the word “merge” or “yield” underneath. Is that the kind of work that you do, or do you do purely visual without any lettering?

Mareika Phillips: We often have words that accompany the pictograms that we work on, but we strive to have every pictogram be so clear that for somebody who has low literacy or is struggling to read in the moment, it’s still clear what the concept is that they need to absorb or learn.

Helen Osborne: Tell us what are the benefits and beauty of this. How do they help people? You talked about people who are struggling to read. How else can visuals help people understand the information that they must absorb?

Mareika Phillips: I don’t know if everybody who’s listening to this podcast would relate, but there’s some evidence that over 60% of people are visual learners. Even if somebody is able to read very easily, having an accompanying graphic or pictogram on whatever material you’re trying to represent can only help them understand the concepts that you are putting across.

Helen Osborne: I know that’s for me. I certainly look at pictures. If I’m scanning something, I’ll probably look at the pictures and then I might read the words underneath it. But I certainly look at the pictures there.

Are there any downsides to using visuals this way?

Mareika Phillips: You’re asking a designer. I’m going to say there are probably very few downsides. The only downside I would say is if perhaps the content doesn’t exactly lend itself to a pictogram and you’re sort of forcing it in there, but it doesn’t actually help with understanding.

That’s a little complex to evaluate probably, but you don’t want to overuse visuals or have visuals in place just for the sake of having a visual. You want to make sure it’s actually supporting the content that you are trying to get across.

Helen Osborne: I’m back to my image I made up and it’s still swirling in my brain, about some grown-up putting medication away from the kid. Would it matter if they represent the audience in terms of culture, race, ethnicity and all those different ways, or is it a stick figure that everyone could represent? Or is it more detailed so you include people but perhaps not include everybody?

Mareika Phillips: That’s actually one of the top tips that we give folks who are looking to improve their pictogram best practices. One of those is “tailor to your audience.” We do recommend that if you have a specific audience that you’re communicating to, you create pictograms that reflect that audience directly.

A great example is we did a huge design scan of COVID-19-related icons internationally to get these recommendations together.

Helen Osborne: That sounds fascinating.

Mareika Phillips: This is where I get really nerdy and excited about this sort of stuff.

There’s a great photograph of a Hasidic Jewish man looking at icons of how to cover your mouth when you cough. The pictograms themselves are of a Hasidic Jewish man, so it’s very relatable. It looks exactly like the person who’s engaging with the material. That makes it that much more engaging and understandable to the audience.

Helen Osborne: To that very specific audience. But that probably would not be as useful in something everybody around the world would get, because that’s a very narrow subsection, Hasidic Jews.

Mareika Phillips: Yes. If your audience is more of a general audience, you’d probably want to pick somebody who could represent anybody in your audience, but you would want to actually stay with that one character. That’s actually another tip that is maybe a little counterintuitive.

Say you wanted to represent a vast swath of your population. When you had a series of icons about how to wash your hands, you would have different types of people from different racial and ethnic backgrounds, different ages and different genders all washing their hands. That can actually increase the cognitive load for somebody who’s engaging with those materials.

Helen Osborne: Really?

Mareika Phillips: Yes. You’d want to stick with one character throughout that whole series of pictograms.

Helen Osborne: That’s interesting. I never knew that tip before.

I just want to put this into context, because I want to hear more of your tips. You talked about your pictogram best practices, and I want to hear them. I bet our listeners do too.

But I also want to know are these for people like you who are skilled in the arts and the ones drawing it, or do you have tips for those of us who may not be as artistic or that’s not what we’re doing, but we need to get our message across, like the great health communicators, whether we’re clinicians or public health or designers?

I think that the listeners of Health Literacy Out Loud are people who just want to make their materials better today than they were yesterday.

Who are you talking about when you give these tips, or is there something for all of us to learn?

Mareika Phillips: I feel like it’s just what you said, Helen. There’s something for everybody to learn here. These would definitely be tips that would directly apply to graphic designers or illustrators who are creating pictograms. But it’s also a way for folks who don’t have access to a graphic designer or an illustrator to evaluate their own pictograms or choose their own pictograms from online.

These tips can really apply across the board to whoever is creating pictograms for health literacy reasons.

Helen Osborne: So it sounds like whether you’re the one who’s creating it, you’re choosing it or you’re using it somehow or evaluating it.

Okay. Go for it. Tell us some good tips we can all use.

Mareika Phillips: Great. They broadly fall under four categories. The first one is “reduce cognitive load.” I know that that’s a big word that maybe not everybody is familiar with. What I mean by “cognitive load” is just the amount of information someone can take in and keep in their short-term memory at one time.

We want to reduce the amount of information that we’re giving people at a time and only crystallize it to the absolute most important pieces so that they’re absorbing those important pieces and not having to worry about anything that’s extra.

Helen Osborne: Can you give us an example, please?

Mareika Phillips: Absolutely. One of those I already went over, which is if you use a character, to keep it consistent.

Another one would be to use a consistent visual style between your pictograms. You don’t want to be using silhouettes for one, outlines for another and then a filled-in, fully colored pictogram style for another. You want it to all be consistent.

Helen Osborne: The same character, the same kind of style. You wouldn’t probably mix a photograph with a simple line drawing, perhaps.

Mareika Phillips: Yes, that’s exactly right.

Another broad category that we have is to use literal representation, which is something we touched on earlier, and avoid abstract symbolism. This is a great one, especially if you have a very broad audience in your material.

If you are having all kinds of people interacting with your material, you don’t know what symbols actually mean in their individual cultures, or if they’re familiar with even something that may seem obvious to somebody from the United States or another westernized country.

Again, a lot of times we have pictograms that have characters in them. If you use a character, make sure to keep their face.

Helen Osborne: Keep their face?

Mareika Phillips: Yes. We have seen some pictograms come out, even of some high-ranking public health official places that I won’t name, where they have no eyes, no mouth, no nose. It’s just a blank face.

Helen Osborne: I’ve seen those. It’s just a head.

Mareika Phillips: Exactly. That’s not the best practice for a general audience.

Helen Osborne: I’m intrigued. Why?

Mareika Phillips: If you have a general audience, it includes folks who have cognitive disabilities. They may not understand looking at your drawing without a face that that’s actually a person.

Helen Osborne: Thank you for explaining that.

You also talked about doing a real representation, a literal one. If your key message is “Do not do this,” maybe it’s an icon, a circle with a line going through it. Is that a pictogram no-no?

Mareika Phillips: It is. That’s a great question. What we say at Communicate Health is to always focus on what to do and not what not to do. If possible, don’t show what you’re not supposed to do. Show the actual positive, what to do.

If we’re using the “wash your hands” example, your message should be, “When you come home, wash your hands,” not, “When you come home, don’t forget to wash your hands.” It’s that sort of thing.

Helen Osborne: Thank you for that. I know that’s a whole philosophy and I try to do that. All the plain language writing I’m doing is really focused on what you can do, not what you cannot do.

As far as the visual symbol, a circle with a line through it or an X, is that understood around the world? Or even a traffic light with a red light rather than a green light?

Mareika Phillips: I’m not sure about the circle with the line through it. I would assume that is a relatively universal one. If you were to use that, you might want to ask your audience if they understand what that is.

I will say for the traffic light, the stop light with red, yellow and green, I wouldn’t consider that a universal symbol across the entire world. If you have a general audience where you don’t know where folks are coming from, that’s the type of abstract symbolism I would avoid.

Helen Osborne: Thank you for explaining that and giving your perspective on this.

We only have a couple more minutes. What other tips would you want all of us to know, whether we’re designers or producers of materials or just the one recommending what should be done?

Mareika Phillips: Another great tip is to use realistic color. If you’re going to be using color in your pictograms, you would want that color to be representing what is actually happening.

If you’re representing heat, for example, you would want to make sure that is red or orange or reflects warmth.

You don’t want to be using color that doesn’t actually apply to the scene. An example of what that would look like would be if you just have a blue overlay over your entire pictogram, but it’s actually representing a concept that has nothing to do with being cold or sad. That’s not going to be a best practice.

Helen Osborne: That’s great. I just want to keep hearing more about this. I don’t know if there’s a way or a resource we can learn more. If so, we will put that link on the Health Literacy Out Loud website.

What tip or strategy do you want to leave with us that we can go forth and just feel a little bit more confident in using pictograms in our work?

Mareika Phillips: I would say, just generally speaking, the key is radical empathy and really putting yourself in the shoes of your audience members, remembering that we all have biases that we have to fight against and step outside of in order to really address our audience.

Helen Osborne: That’s great. Big words here. Radical empathy, I think we could just focus all on that one. But since visuals matter so much, we have to pay attention to not only the direct message we’re trying to give, but the other messages that our illustrations might be conveying. Is that correct?

Mareika Phillips: Yes.

Helen Osborne: Thank you so much. Do you want to just share the URL for Communicate Health so everyone can get your newsletter, which is a real goodie?

Mareika Phillips: Sure. You can either sign up at www.CommunicateHealth.com, or you can go to www.Medium.com/wehearthealthliteracy and you’ll find our whole backlog of posts there.

Helen Osborne: Thank you. I just want to tell people that it’s not spelled out “we H-E-A-R-T health literacy.” There’s a picture of a heart. I don’t know if it’s supposed to mean love or our beating hearts, but either way, it’s visual right in its title.

Mareika Phillips: That’s true.

Helen Osborne: Thank you so much for all you do and for sharing these great tips and best practices with all of us on Health Literacy Out Loud.

Mareika Phillips: Thank you so much for having me. It was definitely my pleasure. I hope it was helpful for the listeners as well.

Helen Osborne: As we just heard from Mareika Phillips, it is important to consider our visual representation, our pictograms, our icons as much as it is our words. But doing so in ways that everyone can learn from and relate to is not always easy.

For help clearly communicating your health message, please take a look at my book, Health Literacy from A to Z. You might be especially interested in Chapter 38, called “Visuals.”

Feel free to also explore my website, www.HealthLiteracy.com, or contact me directly at helen@healthliteracy.com.

New Health Literacy Out Loud interviews come out every few weeks. You can get them all for free by subscribing at www.HealthLiteracyOutLoud.com, or wherever else you find your podcasts.

Please help spread the word about Health Literacy Out Loud. Together, let’s tell the whole world why health literacy matters.

Until next time, I’m Helen Osborne.

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