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Text may not always be enough when giving written instructions
Consider illustrations to clarify, underscore message
Some say a picture is worth a thousand words. People in the field of patient education might add the word: "sometimes."
Drawings can help to clarify instructions, says Christine Hess, MEd, patient and family education coordinator at Wellspan Health in York, PA. Text may seem to give explicit instructions, but a line drawing will underscore the content to make sure the reader understands, she explains.
Line drawings may bolster comprehension, particularly for the person who is a visual learner, like Hess. She says she likes to be shown how to do something. "In my brain, the picture ties into the whole meaning," she explains.
Text, coupled with a drawing, reinforces the message, making it easier to recall, explains Hess.
Fran London, MS, RN, a health education specialist at The Emily Center at Phoenix (AZ) Children's Hospital, says she uses illustrations when she wants to reinforce or demonstrate a desired behavior, such as the angle at which to inject a medicine.
Frequently, she refers to the chapter on this topic in the book "Teaching Patients with Low Literacy Skills" by Len and Ceci Doak.1 Now out of print, the book is available for free download from the Internet. (To learn how to obtain information from this book, see Reference at the end of this article.)
The authors of this book advise the use of visuals "to give a sense of realism by helping the patient see the action recommended," says London.
According to the Doaks, illustrations are particularly useful when trying to communicate complex concepts. Visuals to show a step-by-step procedure can be logically grouped to make the sequence easier to learn than an explanation from text, say the Doaks.
Illustrations can serve as a guide for how to do an exercise, and they help "show" what the words intend, agrees Diane Moyer, BSN, MS, RN, program director for patient education at The Ohio State University Medical Center in Columbus.
"Any visual should add to or highlight a message in patient education materials," says Moyer. Photos or illustrations can be very important, but they should be thoughtfully added and tested to be sure the intended message is being conveyed by the visual.
Photos, line drawings, and sketches can increase understanding for patients with low literacy when used appropriately, says Moyer.
The sketch must be a general concept that is common knowledge, adds Hess. For example, a telephone is not visualized by all as a landline. Younger members of society may visualize a cell phone when thinking of such a communication tool. Therefore, when using illustrations, it is important to think of the cultural reference points and life experiences of the readers, she says.
London says that the type of illustration is important when trying to educate people with poor literacy skills. Computer clip art and stylized images are not readily identifiable by those with poor literacy skills, according to the Doaks. These authors recommend showing the text with pictures to a focus group to make sure the meaning of the illustration is clear.
To make sure the illustration depicts its intended message for all audiences, Hess uses a lay person review board at her health care institution to look at newly developed materials.
Moyer adds that a poor choice of illustrations can send the wrong message and be inappropriate.
"If you are illustrating what not to do, it is important to put a big X across the picture, so poor readers don't misunderstand that the picture shows what they should do," she warns.
When determining whether to use a photograph or drawing, consider the purpose of the illustration, advises Moyer. Photographs are often great for showing emotion and, if done well, can also show equipment and steps in a procedure. However, it is important to be sure the photographs are clear and to the point, she adds.
"A line drawing can keep the message simpler and less cluttered," says Moyer.
London agrees. Research shows line drawings eliminate unnecessary details, she explains. For example, in a photo, the reader may notice the red nail polish on the hand performing the task, rather than noticing the way the task is performed in the picture.
Digital cameras make it easy to take photos fairly inexpensively, says Moyer. But not everyone has the ability to edit the photos to adjust the shading and other features to make them work, she adds.
Also, if the written material will be printed in black and white, the photograph may not transfer well, says Moyer.
She says The Ohio State University Medical Center has no written policy on incorporating illustrations into written materials, but they are not used to make a piece look "pretty." "Illustrations are used to clarify or highlight the intended messages," says Moyer.
Illustrations may be added to show a piece of equipment to give the patient some idea of what to expect, to show exercises, and step-by-step instructions for things like giving injections or dressing changes. "We have mostly used simple line drawings," says Moyer.
Because line drawings require a skilled illustrator, they are often more costly than photos. Also, it can be difficult to find someone with the skills to do simple medical illustrations, she adds.
"We have been fortunate to have a contracted artist that we have used for many years. We have a fairly extensive inventory of illustrations that we are actually cataloging now, so that we are better able to know what we have and potentially may be able to make them available for others to use," says Moyer.
At Wellspan Health, the decision on whether to include illustrations with written materials is left to the patient education coordinator and the lay person review committee. While illustrations usually are used to enhance clarity, they also can be added for visual appeal if a document is too text-heavy, says Hess.
Illustrations are selected from basic, free clip art or licensed medical clip art that can be used for a fee. Also, Hess, who has studied art, will create a simple line drawing from a picture.
If the selected clip art is in color, Hess prints it out to see what it looks like in the gray color scale. "I tend to stick with black and white and the gray scale, because some of the documents are on a portal and can be printed on the unit," adds Hess.
Phoenix Children's Hospital uses line drawings of behaviors and includes captions. This policy is based on the Doaks' score for "Suitability Assessment of Materials," which includes criteria for illustrations. This assessment tool is in their book, says London.
The health care institution hires an artist to create its line drawings. London says the authors of the handout often take photos of the behaviors they want to reinforce, and the artist makes line drawings from the photos, showing only the essential features of the action.
To select an appropriate image, Moyer considers the message to be conveyed; the target audience, whether from a particular culture or age group; and the labels or captions needed to clarify the message of the illustration.
Moyer says that medical illustrations are often too complex and detailed to be good for patient education materials. She recommends keeping concepts simple. For example, when she wants to show a particular part of the body in an illustration, she uses the outline of the whole body and then pulls a second illustration from the body to show more detail, such as the location of the heart.
1. "Teaching Patients with Low Literacy Skills," C.C, L. G. Doak, et al. (1996) Philadelphia, J.B. Lippincott Company available for free download at: http:/www.hsph.harvard.edu/healthliteracy/files/doak5-7.pdf.
For more information, contact:
* Christine Hess, MEd, patient and family education coordinator, Wellspan Health, York, PA. Telephone: (717) 851-5859. E-mail: firstname.lastname@example.org.
* Fran London, MS, RN, Health Education Specialist, The Emily Center, Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016-7710. Telephone: (602) 546-1408. E-mail: email@example.com.
* Diane Moyer, BSN, MS, RN, Program Director, Patient Education, The Ohio State University Medical Center, 660 Ackerman Road, Room 667, P.O. Box 183110, Columbus, OH 43218-3110. Telephone: 614-293-3191. E-mail: Diane.Moyer@osumc.edu.