Capture patients' attention with a photonovela

Creativity, collaboration key to success

People in health education are beginning to use a literature genre called a photonovela. This genre tells a picture story and is designed like a comic book with text in bubbles to indicate who is speaking.

William Smith, EdD, executive vice president for the Academy for Educational Development in Washington, DC, says photonovelas work best as an educational tool when viewed as an act of entertainment that coincidentally educates, not as a picture book curriculum.

"I think it is an entertainment medium which is terribly powerful as an education[al] one, as well," says Smith.

A visual medium with simple text, this written format works well with patients who have low literacy skills, says Susan Auger, MSW, owner of Auger Communications, a consulting and educational services firm in Durham, NC.

At the core of every photonovela is a story, and storytelling is a universal way of educating and sharing information, adds Auger. This makes it a relevant educational tool for many cultures.

A photonovela needs to have humor when appropriate, drama, and familiar language. Health care professionals tend to want to edit the drama out of the text, leaving only facts, yet a photonovela is not created by changing a brochure into dialogue bubbles, says Auger.

Photonovelas have been created to provide education on gestational diabetes, prenatal care, how to re-hydrate a baby, the prevention of HIV-AIDS, depression, post-traumatic stress, and substance abuse.

However, to make sure a photonovela adds up to time and money well-spent, it is important to pinpoint the learning objective up-front.

The Center for Addiction and Mental Health in Ontario, Canada, produced photonovelas targeting its immigrant communities on five topics that included depression, post-traumatic stress, drugs, alcohol, and gambling. This project began with the goal of improving mental health, addiction literacy, and service access, says Antoine Derose, BSW, the program consultant for policy, education and health promotion at the center.

The five topics to cover — and the decision to deliver the information in the form of photonovelas — came from the community members. It was gathered by holding a number of focus groups. Derose says the community members clearly stated they did not want to receive information in pamphlets with lots of scientific facts. Instead, they wanted something that was easy to read and would not draw attention to the reader.

There is strong stigma around mental health issues in many communities. People wanted to make sure that if they were reading something about depression or other mental health issues, those observing the material would not make assumptions about their reasons for getting information, says Derose.

Two creative styles

Once the topic and learning objective is selected, the creative process must be determined. Auger says there are two ways to create a photonovela. One is the community-controlled process where various members take the lead on script writing, the photo shoot, design, printing, and distribution.

"It is empowerment based in terms of community members taking control of the process. You've got health professionals that are seen as the outsiders who provide technical assistance," explains Auger.

The second process is to balance input between community members and health professionals, acknowledging that both have an important perspective. This team approach was used in the creation of a photonovela on gestational diabetes for Latino women.

To determine the meaning of diabetes and gestational diabetes for Latino women, Auger and her colleagues began to research diabetes programs that served the Hispanic community in the United States and also diabetes programs in the Latin American countries and Mexico, from which these women emigrated.

In addition, focus groups made up of Latino women who had experienced gestational diabetes were held. From these groups, a woman was identified to write her story in Spanish explaining her experience with gestational diabetes.

"That was the starting point of the photonovela," says Auger.

The woman's personal story was then given different dimensions to make it more universal. It was tailored to fit various teaching issues, different themes that emerged during research, and difficult teaching points or misconceptions. Two groups were formed to oversee the development process for the photonovela. They included a community advisory board and an expert advisory board made up of a multidisciplinary team that included diabetes educators, physicians, and midwives who served pregnant Hispanic women.

To determine whether to use the community oversight method for creating a photonovela or team effort, know your learning objectives, says Auger. If the goal is to create behavioral change within a particular group of people or a geographical location, then have them create the story and take ownership, she advises. If the goal is to create a more universal story that is relevant to a lot of people, then the team approach might be more appropriate.

An example of a community project is a photonovela created in the Dominican Republic, on which Smith worked. This piece was created to promote the use of condoms to prevent the spread of AIDS and was aimed at female sex workers, who were a key element in the creation process. The photonovela was about a man who would pay the sex worker more if she did not insist they use a condom. The tricks female sex workers actually used to talk the man into using a condom were woven into the story.

An imaginative artist worked with the female sex workers to develop the materials. "The storyline lent itself more to drawings. The photonovela was like a really hot comic book," says Smith.

The team approach was used by the Center for Addiction and Mental Health to create photonovelas that could reach a wide array of people. The idea was that these materials, which were written in French, could be translated into English, Spanish, and other languages to serve a wide array of people.

The teamwork was a time-intensive process, but it helped make the piece balanced. The community group and health care professionals worked closely to develop the storyline, according to Saroj Bains, creative consultant and production manager on the project. Also, a professional script writer was hired.

"We went into a writer's workshop where everyone had the scripts in front of them, and we went through it line by line, word by word to determine if one character would say something or if a better word might be used. That was the attention to detail that was foremost in the development of these photonovelas," says Bains.

The photonovelas were shot with a professional photographer and production team in public schools, because it is one location where diverse populations gather. Each topic was covered through snapshots of situations pertaining to a particular mental health issue. For example, in the photonovela on post-traumatic stress, a young boy is playing in the schoolyard with other children when a loud noise from a nearby construction site prompts him to run to the restroom to hide. He emigrated from a country at war and experienced a flashback. Through this story, the concept of post-traumatic disorder is explained.

Before the photo shoots, storyboards were sketched that determined the position of each person in the photograph. Each shot had been approved by the advisory boards.

When creating a photonovela, the production team must not only design the product, but also determine the distribution process. How the piece is distributed depends on its purpose.

The photonovelas pertaining to mental health issues were distributed to school boards, public libraries, community health care centers, and other sites where the target audience would have access to them.

Auger says the photonovelas she helps to create often are used in educational settings, read like a play, and discussed.

One of the strengths of a photonovela is it allows many different dimensions to be part of the story. For example, with the gestational diabetes photonovela, it was clear that when women were first diagnosed, they just heard the word "diabetes" and were gripped with fear because of bad outcomes experienced by close relatives. Therefore, the photonovela focused on the emotional impact of learning about diabetes.

To capture these dimensions and thus take full advantage of the photonovela as an educational tool, it is important to ask the right questions of the target audience, really listen, and then let go of the notion of being the expert, says Auger.