Can theory be embedded in visual interventions to promote self-management? A proposed model and worked example

International Journal of Nursing Studies 49 (2012) 1598–1609

Contents lists available at SciVerse ScienceDirect

International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns

Can theory be embedded in visual interventions to promote self-management? A proposed model and worked example B. Williams a,*, A.S. Anderson b, K. Barton b, J. McGhee c a

Nursing, Midwifery & Allied Health Professions Research Unit, University of Stirling, United Kingdom Centre for Public Health Nutrition, University of Dundee, United Kingdom c Department of Media, Arts & Imaging, University of Dundee, United Kingdom b

A R T I C L E I N F O

A B S T R A C T

Article history: Received 18 December 2011 Received in revised form 4 June 2012 Accepted 7 July 2012

Nurses are increasingly involved in a range of strategies to encourage patient behaviours that improve self-management. If nurses are to be involved in, or indeed lead, the development of such interventions then processes that enhance the likelihood that they will lead to evidence that is both robust and usable in practice are required. Although behavioural interventions have been predominantly based on written text or the spoken word increasing numbers are now drawing on visual media to communicate their message, despite only a growing evidence base to support it. The use of such media in health interventions is likely to increase due to technological advances enabling easier and cheaper production, and an increasing social preference for visual forms of communication. However, the development of such media is often highly pragmatic and developed intuitively rather than with theory and evidence informing their content and form. Such a process may be at best inefficient and at worst potentially harmful. This paper performs two functions. Firstly, it discusses and argues why visual based interventions may be a powerful media for behaviour change; and secondly, it proposes a model, developed from the MRC Framework for the Development and Evaluation of Complex Interventions, to guide the creation of theory informed visual interventions. It employs a case study of the development of an intervention to motivate involvement in a lifestyle intervention among people with increased cardiovascular risk. In doing this we argue for a step-wise model which includes: (1) the identification of a theoretical basis and associated concepts; (2) the development of visual narrative to establish structure; (3) the visual rendering of narrative and concepts; and (4) the assessment of interpretation and impact among the intended patient group. We go on to discuss the theoretical and methodological limitations of the model. ß 2012 Elsevier Ltd. All rights reserved.

Keywords: Nursing methodology research Visual aids Audio–visual media

What is already known about the topic?  Nurses are increasingly involved in design and delivering behavioural interventions, especially those that aim to improve self-management.

 Visual interventions are becoming more common despite an evidence base that is lacking in scope and rigour.  Interventions must be developed and defined in detailed and rigorous ways in order to maximise their contribution to establishing an evidence base for visual interventions. What this paper adds

* Corresponding author. E-mail addresses: [email protected] (B. Williams), [email protected] (A.S. Anderson), [email protected] (K. Barton), [email protected] (J. McGhee). 0020-7489/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijnurstu.2012.07.005

 There are good theoretical reasons and growing empirical evidence to indicate that visual interventions may be

B. Williams et al. / International Journal of Nursing Studies 49 (2012) 1598–1609

an effective means of influencing behaviours and its precursors.  Psychological concepts and behavioural theory can be embedded in visual form through consideration of a wide array of visual parameters.  A rigorous and systematic approach to creating theoretically informed visual interventions should consider four stages: the identification of theoretical basis, establishing a narrative, rendering theory in visual form, and pilot testing. 1. Nursing involvement in the development and delivery of behavioural interventions Nurses are increasingly involved in a range of strategies to encourage patient behaviours that improve selfmanagement (Coster and Norman, 2009). These can include the delivery of behaviour change interventions around health behaviours such as smoking cessation, alcohol consumption, diet and physical activity. At other times a range of clinical reviews may include conversations regarding appropriate use and adherence to prescribed medications or therapies. For example, conditions such as asthma, diabetes and COPD are largely managed by routine review conducted by nurses within both primary care and out-patient settings. In addition, nurses are increasingly central to both the design and the delivery of rehabilitation programmes for cardiovascular disease, heart failure, COPD, cancer and stroke. Given the increasing centrality of behaviour change to many nursing activities it is unsurprising that there is a growing interest in nurses being involved in the design of behavioural interventions which they are expected to deliver, and which may influence not only behaviour but also their patients’ wider experience of illness and views of service provision. Nursing involvement in the design of such strategies is likely to be a first, and potentially essential, step towards addressing what has been seen as a lack of clarity as to how nurses can support the self-management agenda (Macdonald et al., 2008). If nurses are to be involved in, or lead, the development of such interventions then processes that enhance the likelihood that they will lead to evidence that is both robust and usable in practice (Greenhalgh, 1998) are required. Poorly conducted or reported intervention development processes can lead to reduced effectiveness, interventions that may work in the ‘‘ideal’’ conditions of a clinical trial but not in the real clinical world, or interventions that may work but are so poorly defined that they can never be replicated by practitioners (Steckler and McLeroy, 2008). Indeed a recent review of Cochrane reviews identified a significant lack of clarity in definitions of nursing interventions designed to support self-management (Coster and Norman, 2009), particularly in relation to the identification of key components. A number of attempts have been made to address this. Glasgow and colleagues have proposed the ‘‘RE-AIM’’ framework that seeks to ensure that any evaluation of a behavioural intervention systematically examines a number of key relevant areas: Reach, Efficacy, Adoption, Implementation and Maintenance (Glasgow et al., 2001). In parallel, criteria

1599

to improve the reporting of behavioural and public health interventions through the Transparent Reporting of Evaluations using Non-Randomised Designs (TREND) have been published in an attempt to mirror the success of the CONSORT statement in relation to randomised controlled trials (Jarlais et al., 1994). Although both RE-AIM and TREND may have an impact on intervention reporting, and indirectly on study design, they do not clearly address intervention development or demand anything other than general descriptions of the intervention itself. In particular, neither requires an explicit statement or description of the link between underlying theory and the actual components of the intervention. Furthermore, neither requires that the process, data or associated lessons learnt within developmental stages be made explicit. These, however, may be important findings in order to inform judgments regarding likely generalisability to other populations, assessments of potential practical problems of local implementation and the acceptability of adaptation of some components (Michie, 2008; Michie and Abraham, 2004). Furthermore, researchers employing similar theory may benefit from the experiences of others seeking to apply that theory in new forms or contexts. The most appropriate guidance to both research conduct, and perhaps subsequent reporting, in this context is possibly the UK Medical Research Council Framework for the Development and Evaluation of Complex Interventions (Craig et al., 2008). This paper seeks to explain the process and methodological lessons learnt from applying the MRC Framework for the development of complex interventions (Craig et al., 2008) to the development of a visually based behavioural intervention to be delivered by nurses or allied health professionals. The proposed model at the heart of this paper (Fig. 1) was developed in response to the needs of a specific research project, HealthForce (Craigie et al., 2011) but may be of wider use to those wishing to develop similar visually based interventions. We first provide brief background detail regarding HealthForce prior to three substantive sections: a description of the theoretical and empirical support for the use of visual interventions; a description and worked example of the proposed model; and then finally a discussion reflecting on the limitations of the model and associated methodological and ethical considerations. 2. The ‘‘HealthForce’’ project In 2005 funds were awarded by the United Kingdom’s (UK) National Prevention Research Initiative to develop and pre-test a multi-component weight and lifestyle management programme, HealthForce. HealthForce, was aimed at changing health behaviours associated with risk reduction of cardiovascular disease, cancer and diabetes. Individuals aged over 50 who had been identified as at risk were to be referred into the intervention. A staged intervention covering a three month period was developed based on existing relevant theory and empirical studies in the area. However, there was acknowledgement that maximising uptake and engagement was an essential pre-requisite of intervention

Stage 1: Establishing a theorecal basis: the creaon of conceptual content

Modelling (MRC Phase 2)

Stage 2: Modelling Structure: creang a visual narrave Aim: To create a model of the intervenon and idenfy key relaons between components.

Stage 3: Modelling the “look”: visual rendering of narrave and concepts Aim: To create a prototype of the animaon and refine through ongoing feedback

Idenficaon of Important and Feasible Visual Parameters for Manipulaon

Suggested methods:

Suggested methods:

Suggested methods:

• Creaon of a cohesive narrave. • Visual embodiment of narrave through a theory-informed storyboard. • Ongoing discussion and adaptaon of the storyboard.

• Examine sociological and anthropological conceptualisaons and lay perspecves. • Explore colour theory, semioc s, iconography and aesthecs. • Create images/ sound and reflect on parameters and oponal variables

• Inial unprompted and un-narrated showing followed by in-depth interview to check interpretaon. • Small scale trial with appropriate psychological scales related to embedded components • Allow use of “think aloud” method for parcipants.

Consideraons: • Theory must be empirically supported. • Theory and concepts must be relevant to the topic area • Concepts must be capable of being visually communicated.

Tips: • Engage with arsts at earliest possible stage. • In discussions note the visual parameters that are discussed.

Aim: To establish the understanding, acceptability and likely impact of the intervenon. Aim: To seek suggesons for final improvements from potenal users and recipients

Ongoing Iteraon

• Form muldisciplinary group of behavioural sciensts, health professionals, animators/arsts. • Establish paent involvement and exisng qualitave research.

Stage 4: Modelling – Checking: Establishing interpretaon and potenal impact

Consideraons: • Consider the appropriate start and end points for the narrave. Do you wish to use the narrave to explain the paents’ current state, or to suggeson future risks, or both?

Tips: • Mulple future narraves may be appropriate in order to demonstrate both risk and self/treatment efficacy.

Consideraons: • Consider ethical implicaons of any move from realism and emphasising a value (e.g. increased severity). Are you misleading paents?

Tips: • Beware of researcher over-exposure to the images. Show dra animaons to a range of others.

Fig. 1. A model for the development of theory-informed visual interventions.

Consideraons: • Consider purposive sampling in inial stages in order to access wide variaons in interpretaons. • Consider views of both paents/ public and health professionals.

Tips: • Watch parcipants’ facial expressions for emoonal reacon.

B. Williams et al. / International Journal of Nursing Studies 49 (2012) 1598–1609

Aim: To idenfy relevant theory to inform the desired aims, structure, content and format of the images.

Suggested methods:

1600

Theorecal Basis (MRC Phase 1)

B. Williams et al. / International Journal of Nursing Studies 49 (2012) 1598–1609

efficiency and effectiveness. After further examination of relevant theory and literature it was decided to explore the feasibility of developing and utilising a visual intervention to explain to participants why they were at high risk and to motivate them to take up the three staged behavioural intervention. 3. A theoretical and empirical rationale for image-based interventions Images, whether through posters or television advertisements, are increasingly being used in attempts to change health behaviours. However, such interventions are often developed inductively and iteratively through focus group consultation, and may therefore lack explicit theoretical and empirical underpinning (Williams and Cameron, 2009). Furthermore, the evidence base to support the effectiveness of visual interventions is in its infancy, thereby making rigorous intervention development and theoretical underpinning even more vital. The failure to engage with theory known to support behaviour change may reduce the efficiency of the development process and the ultimate effectiveness of interventions and the wider evidence base for visual interventions. The rationale for images being a potentially useful tool is based on the fact that images are known to influence two key determinants of behaviour: emotion and cognition (Bradley and Lang, 1999; Ito et al., 1998). 3.1. Images, cognition and behaviour Cognitive processes such as health, illness and risk representations are known to influence behaviour both via, and independently of, any impact on emotion (Hagger and Orbell, 2003; Leventhal et al., 1980). However, there is increasing evidence that such cognitive representations may frequently be embodied in non-verbal forms (Damasio, 1994). This suggests that visual media may be an appropriate means by which these cognitions might be influenced (Lee et al., 2011). For example, it is now known that patients develop mental images of their inner body and the disease process (Harrow et al., 2008a,b; Mabeck and Olesen, 1997). These images frequently include illness beliefs (Guillemin, 2004) which have been found to affect illness experience (Kleinman et al., 1978a,b), behaviour (Lang et al., 2007), service use (Broadbent et al., 2006) and health outcomes (Broadbent et al., 2004a,b, 2006). Moreover, research suggests that many lay beliefs about human anatomy and physiology is highly metaphorical (Kleinman et al., 1978a,b; Sontag, 1978), inaccurate (Boyle, 1970; Kleinman et al., 1978a,b), and influences behaviour (Helman, 1985, 1978; Kleinman, 1988; Kleinman et al., 1978a,b; Sontag, 1978). There are good theoretical reasons for why visual interventions may be effective in these situations. For example, Leventhal suggests that illness representations lie on a continuum from abstract/conceptual to concrete/ experiential (Cameron, 2003; Leventhal et al., 1980) and representations that are increasingly concrete have the potential for greater impact. Visual animation may move such representations from abstract knowledge to more

1601

concrete experience. This theory also concurs with work in semiotics which suggests that communication may be deconstructed into ‘‘modalities’’ and ‘‘medium’’. Modalities are the qualities of sense based perceptions for example, auditory modalities include pitch (high–low), volume (loud–quiet); visual modalities include hue (bright–dark), focus (sharp–dull), distance (far–close) and so on. Medium refers to the form through which the message is communicated e.g. text, speech, sound, visual. A message may employ multiple modalities. The more of these modalities that are embodied via the medium then the greater the ‘‘sense of reality’’ that will be achieved (Chandler, 2007). In computer graphics this increased sensory communication is regarded as the key to achieving ‘‘presence’’, that is, the sense that a virtual representation is somehow present and real (Luciani et al., 2004). The ability of image and sound to shift representations into more concrete experiential form is supported by research examining the impact of women’s experience of ultrasound scans of their unborn child (Dykes and Stjernqvist, 2001). Langer and colleagues found that the vivid imagery presented through scans made the unborn baby more ‘‘real’’, and produced a brisker, more active and more familiar view of the baby (Langer et al., 1988). After ultrasound, many women show a more positive attitude towards the child and expressed increased closeness and caring for it (Campbell et al., 1982). In terms of health promotion animations (films), the closer the characteristics of both the narrative and visual forms match those of the viewer the greater the likely impact on risk representations (Cameron, 2003). This has been demonstrated through studies showing smokers ultrasound images of their own damaged arteries (Shahab et al., 2007) and recent personalised cardiac animations (Lee, 2007). 3.2. Images, emotion and behaviour There is a known link between emotion and behaviour with positive affect encouraging the pursuit of goals while negative affect tends to lead to avoidance or withdrawal behaviours (Carver et al., 2000). In some cases, negative affect such as anxiety can also enhance sensitivity and vigilance to health threat messages in both the short term and via rumination over longer periods (Cameron, 2003). For example, a study of 213 women with breast cancer reported that moderate worry about cancer facilitated rather than undermined mammography adherence (Diefenbach et al., 1999). Negative affect can also increase attention to short term consequences (Gray, 1999) particularly when prompted by concrete-experiential cues (Gray, 2001) (such as seeing someone vomit) rather than abstract/conceptual ideas. Watching, listening and engaging with visual media are more therefore more likely to form such a concrete experiential cue than reading or listening to words. Consequently, whether through experiential or analytic modes of thinking (Epstein, 1994; Slovic et al., 2003) images may be able to influence both emotional and cognitive aspects of risk awareness and experience thereby changing behaviour. However, there is growing evidence

1602

B. Williams et al. / International Journal of Nursing Studies 49 (2012) 1598–1609

of a range of other likely benefits of images over text based interventions. 3.3. Miscellaneous other benefits of image over words Visual media has other advantages over other forms of communication. Firstly, visual media may be more memorable than verbal or text based messages (Gardner and Houston, 1986; Paivio et al., 1994; Prabu, 1998). Secondly, the propensity of mental imagery to promote rumination suggests that visual media may have a longer term impact (Cameron, 2003); and thirdly, communication via visual media is less dependent on language or literacy skills (DeWalt et al., 2004). The effectiveness of such media may rest more on what has recently been termed ‘‘visual literacy’’ – the ability to use and understand visual media for intentionally communicating with others (Ausburn and Ausburn, 1978; Avgerinou and Ericson, 1997). 4. A framework, and worked example, for developing theory based visual interventions In order to develop visual based interventions that maximise the likelihood of being effective, researchers must attend to three key requirements: appropriate theoretical and conceptual content, a narrative structure around which the intervention message can be organised and conveyed, and the form and medium through which conceptual content should be communicated. We combined these requirements with the principles embodied in phase 1 (establishing theoretical basis) and phase 2 (varying intervention components and combinations to optimise impact) of the MRC Framework to create a model for future methodological use (Fig. 1). The model includes four stages: (1) the creation of conceptual content to establish a theoretical basis; (2) the development of visual narrative to establish structure; (3) the visual rendering of narrative and concepts; and (4) the creation of evidence criteria to establish interpretation and impact. 4.1. Stage 1: Establishing a theoretical basis: the creation of conceptual content Although we would argue that images provide a particularly distinctive and powerful means of addressing concreteness and coherence (and thus adding value and potential effectiveness to interventions), it is likely that the visual form can otherwise simply be seen as the medium through which almost any social cognitive theory could be embedded given careful thought. Identifying theory to inform the desired aims, content and format of the images requires judgments in relation to three criteria. Firstly, is there sufficient evidence to suggest that the theory could reasonably lead to behaviour change? Secondly, are the concepts within that theory operationally relevant to the specific population, clinical topic and behaviour? Thirdly, how can the theory and constituent concepts be communicated in visual form? This stage requires a multidisciplinary group with knowledge of behavioural theory, lifestyle interventions, relevant clinical area, and expertise in visual media to review relevant research, discuss

potential concepts and assess their ability to be communicated effectively through visual media. In particular, this may include systematic reviews, and or meta-syntheses of studies that explore health and illness beliefs with regard to a particular disease or behaviour, followed by primary studies that explore whether and in what ways these beliefs are already embodied in visual forms. Such studies already exist in relation to cancer (Harrow et al., 2008a,b) and cardiovascular disease but are largely lacking in other areas (Broadbent et al., 2004a,b, 2006) and may be helpful to conduct. Once these have been identified then a more informed assessment of the varying theoretical concepts (e.g. self-efficacy, perceived health threat, subjective norm, etc.) and relevant behavioural change techniques (Abraham and Michie, 2008) can be made. An important consideration at this stage is the likely feasibility and potential added benefits of translating and expressing these concepts and techniques visually. 4.1.1. HealthForce – worked example A multi-professional group with knowledge of behavioural theory, lifestyle interventions, nutrition and cardiovascular disease, along with digital animators, was convened. The applicants met on several occasions to review relevant research evidence and discuss potential concepts that met these criteria. This was a highly iterative process as concepts were discussed and then sometimes discarded as their ability to be communicated effectively through visual form was questioned. The agreed theoretical basis for the imaging intervention was eclectic and drew on a number of psychological theories including elements of the health belief model (Becker et al., 1977), self-efficacy (Bandura, 1977), Leventhal’s commonsense model (Hagger and Orbell, 2003; Leventhal et al., 1980; Leventhal and Nerenz, 1985) and Kleinman’s explanatory models (Kleinman et al., 1978a,b). Subjective norm was considered but regarded as too difficult to communicate at a patient specific level and in visual form. Perceived costs and barriers were also considered but given their varied potential content it was judged that any attempt to address all possibilities would add too much content to the visual media and potentially obscure other messages. It was finally agreed that a visual intervention could feasibly be created that aimed to:  Increase ‘‘coherence’’: establish a visual message that conceptually demonstrated the link between obesity, arteriosclerosis, and increased risk of cardiovascular events.  Increase personal perceived susceptibility to cardiovascular events.  Increase perceived severity of arteriosclerosis.  Increase perceived benefits of weight loss.  Increase self-efficacy: the degree to which they believe that they can act to reduce current risk. Intentions to engage in the main lifestyle intervention would hopefully be influenced by raising the individual’s perceived health threat (perceived susceptibility and severity) along with enhancing their belief that their

B. Williams et al. / International Journal of Nursing Studies 49 (2012) 1598–1609

current problems could be addressed and reversed (selfefficacy). These beliefs would themselves be addressed through creating new illness perceptions, in particular an understanding or sense of ‘‘coherence’’ in relation to the basic physiological processes connecting obesity to poor health outcomes. Recent evidence has suggested that the development of such coherence can contribute to the creation of behavioural intentions (Hall et al., 2004; MossMorris et al., 2002). 4.2. Stage 2: Establishing structure: creating a visual narrative The aim of stage 2 is to create a visual narrative, that is, to represent ‘the story’ (message) though consecutive visual images. Narrative has a number of advantages. It can provide structure, retain attention, aid memory (Kulkofsky et al., 2008), and enhance the ability to make causal links between sequential events and thereby construct meaning (Goncalves and Machado, 1999). Furthermore, narrative can project into the future and potentially increase selfefficacy through emphasising a range of possibilities and choices each with varied outcomes (Gagliano, 1988; Healton and Messeri, 1993; Krouse, 2001). ‘Storyboards’ and ‘logic models’ are both potentially useful tools in the iterative development of visual narratives. A storyboard is a series of rough drawings representing a shot-by-shot representation of a planned film, providing a common visual language that people from different backgrounds can ‘read’ and understand (Lelie, 2005). Logic models are diagrams which illustrate and link the major conceptual and practical components of a program in order to reflect the sequence of events necessary for it to be effective (Israel, 2006). Integrating the storyboard concept with the more theoretically based logic model to create a ‘‘theory-embedded story board’’ could facilitate discussions within a research team, helping them to create a narrative sequence with agreed theory embedded within a coherent and meaningful narrative structure. The initial storyboard would establish a sequence to form the overall message and, depending on the content, may contain micro narratives within the overarching narrative. Thus an idea of what to show would be established at this stage. 4.2.1. HealthForce – worked example Our multi-professional group considered narratives that might embody the theoretical underpinnings of the intervention while simultaneously be engaging to the viewer. This led to the creation of four individual ‘‘micronarratives’’ that when viewed sequentially formed a coherent meta-narrative. Storyboards were created and edited through ongoing discussion and are documented in Table 1. Each individual narrative emerged sequentially beginning with a rotating gender free silhouette of a body illustrating BMI level and predominance of weight around the waist. A box then emerges from the chest and illustrates the heart in varying states of health, a third box then emerges from the heart magnifying an artery and illustrating blood flow. A final text box then appears with a summary message regarding health state and/or risk.

1603

4.3. Stage 3: The sensory rendering of narrative and concepts – establishing the ‘look’ and ‘feel’ With the narrative established two stages follow: the creation and refinement of the medium and then its integration into the narrative. The agreed theoretical concepts within the narrative may be communicated, enhanced or undermined depending on a wide range of parameters and sub-dimensions (e.g. colour, texture, complexity) as evident in Table 2. Although development at this stage is again likely to be iterative it makes sense to consider any empirical research that might inform initial decisions. This process may demand engagement with literature located in diverse disciplinary areas: sociology and medical anthropology in regard to common cultural metaphors and analogies of the body (Helman, 1998) (e.g. the plumbing model of the body (Kleinman et al., 1978a,b)), visual (Moriarty, 1995) and social semiotics (van Leeuwen, 2005), iconography (van Leeuwen, 2001), aesthetics (Radley, 1999) and colour theory. Some parameters may go beyond the visual. For example, research applying semiotic perspectives to auditory analysis has found that non-speech sounds can also convey relevant meaning (Edworthy et al., 1991) and could be considered. We suggest that perhaps the most important initial parameter to be agreed within this context relates to where images will lie on a continuum from ‘‘metaphorical’’ to ‘‘realist’’ (e.g. a photographic quality image of human heart beating, a simplified conceptual picture, or a metaphorical representation such as the personification of a human heart in cartoon format). Non-realist images may reduce complexity and thus enhance coherence and understanding but may do so at the expense of concreteness as they still remain abstract images. Realist representations may enhance impact through concreteness but be overly complex and again fail to deliver a clear explanation of the underlying mechanism, reducing coherence. This illustrated a potential trade-off between conceptual clarity, coherence and realism. Constant checking of intervention meaning and narrative clarity at this stage is essential. Given that members of the research team are already aware of the meaning and narrative attempting to be conveyed then the use of focus groups with individuals who are convenient to sample but who have no involvement in the project, or adoption of further potential future recipients of the intervention to the development group itself are likely to be helpful. 4.3.1. HealthForce – worked example Evidence to support the link between specific visual cues (e.g. colour, texture, shape, etc.) and health/illness beliefs (e.g. perceived severity, susceptibility) was identified in some clinical areas (Kershaw et al., 2008); however, none was found in relation to cardiac health. Consequently, we engaged in a cycle of image generation and testing: presentation to the group, reflection, identification of new image parameters and potential variations, proposed adjustment and thus creation of a new image variant. We also consulted a total of eight male and female nonclinical colleagues (varied age, and including academics

1604

B. Williams et al. / International Journal of Nursing Studies 49 (2012) 1598–1609

and administrative staff) in order to contribute to decision making and ensure that the team’s perspective of the images were not losing credibility. Artists within the team were more aware of potential parameters and parameter combinations that could be varied than other team

members and were indispensible. After consultation we decided to include a fourth micro-narrative in order to improve self-efficacy: this visually demonstrated a reduction in plaque, coupled with an improvement in the health of the heart, blood flow and heart rate.

Table 1 Modelling: creating a theory-embedded story board. Storyboard

Logic model and narrative Easy accessibility PC based animation allowing for portability. Useable on both laptop and PC. Potentially available to download over the internet or stream feed. Ease of interpretation We aimed to develop images and reveal them is sequence in a way that the narrative and message could potentially be understood even if there were no additional text or a health professional talking alongside. Simple initial appearance. All elements that will make up the narrative are not revealed at once.

Defining ‘‘normal’’ and healthy A silhouette with a body shape consistent with a healthy BMI appears. Silhouette rotates to provide understanding of fat distribution. A heart with a pink (colour associated with health) appears to be beating at a healthy rate within the silhouette. Associating a healthy body with a healthy heart A more graphic image of a heart appears out of the body – therefore denoting that it belongs to the person in the silhouette. The heart is a healthy colour and is beating in a relaxed manner. The heart can be heard. Enhancing susceptibility A silhouette is chosen not only to allow the person to focus on shape and thus BMI but also to allow for as nongendered a body as possible. If the image had been male and been employed with a woman then this may have reinforced the idea of cardiovascular disease ‘as a ‘‘man’s’’ illness and failed to increase perceived susceptibility. Understanding simple physiology An image section from an artery is extracted to reveal blood flow. The blood movement is timed to coincide with the heart rate. Defining ‘‘normal’’ and healthy The blood is moving along at a relaxed pace and is unobstructed in its path. The sound of flow is smooth. Ease of interpretation Blood is depicted as red cells are rather than liquid in order to easily show movement and speed. Text appears under sequenced bullet points in order to reinforce the linkages demonstrated by the images.

B. Williams et al. / International Journal of Nursing Studies 49 (2012) 1598–1609

1605

Table 1 (Continued ) Logic model and narrative

Storyboard

Associating increased BMI with increased risk A new silhouette with an increased BMI appears. Rotation of the silhouette reveals that fat is centred more towards the central trunk. The heart within the silhouette is beating significantly faster. The extracted image of the full heart is beating at a much higher rate including the sound – conveying urgency. The extracted heart has turned from a health pink to a slightly pink/grey/greenish colour signifying deterioration. Increasing coherence A build-up of plaque occurs within the artery and the remaining blood is seen to be becoming constricted. Blood flow is more laboured and the sound is ‘‘sticky’’.

Associating increased BMI with increased risk A new silhouette with a very high BMI appears. The heart within the silhouette is beating very fast. The extracted image of the full heart is beating at a very high rate with loud urgent beats. The extracted heart looks green/grey and appears very unhealthy. Increasing coherence and severity The build-up in plaque has almost totally constricted the artery. It is clear that blood is struggling to pass – sound is very sticky and not at all smooth and calm. The consequences of the artery becoming blocked appear clear given the increasingly unhealthy appearance of the heart. Increased susceptibility It is clear that unless something changes the artery is about to become blocked. Increase self-efficacy A silhouette with a reduced BMI and slightly reduced artery plaque but more healthy heart appears. Thereby indicating that the process is, at least, in part reversible.

The group decided that the physiological mechanism at the centre of the agreed narrative was too complex to convey in realist form (i.e. coherence would be sacrificed), Table 2 Decision making on parameters and dimensions of images. Parameter

Dimensions or factors considered

1) Narrative 2) Medium a. Text

Structure and Content

Content Font: Small. . .Large b. Sound Content Volume: Fixed. . .Variable Texture: Smooth. . .Sticky c. Image Content i. Realism Real. . .Metaphorical ii. Detail Simple. . .Complex iii. Colour Hue: Weak. . .Strong Gloss: Matt (dry). . .Shiny (slimey) iv. Visible texture Rough. . .Smooth v. Movement Speed: Slow. . .Fast Flow: Smooth. . .Jerky 3) Integration of narrative and medium a. Sequence Logical linkage of image, sound and text b. Timing Co-ordination of timing between image, text and sound

but also that a metaphorical representation might lessen impact through excessive abstraction. Some details were added (e.g. LDL cholesterol, white blood cells and texture within the artery wall) but then removed in order to preserve conceptual clarity and visual coherence. The final version of the animation therefore provides an essentially simple conceptual representation of the mechanisms involved. The decision to move away from pure realism also gave us the freedom to consider modifying other parameters (e.g. colour of the heart) in order to visually convey health or illness (e.g. from pink/red to green/grey). At this stage it was also decided that an additional sensory parameter could also convey health or illness: sound. Research applying semiotic perspectives to auditory analysis had suggested that the design of non-speech sounds to convey meaning to the user, known as ‘‘earcons’’, was possible (Jekosch, 2005), could convey relevant meaning and urgency (Edworthy et al., 1991). The group believed that audio recordings of blood flow synchronised with the heart could be used to convey a healthy vascular system and a system under stress through faster beats and increased pitch. These were obtained through Doppler ultrasound, presented to the group and parameters adjusted in order to

1606

B. Williams et al. / International Journal of Nursing Studies 49 (2012) 1598–1609

support the associated visual cues within the animation (e.g. heart rate speed and change from smooth to ‘‘sticky’’ blood flow).

that may help guide other researchers in their attempt to embed behavioural theory in visual interventions. 5.1. A framework for developing visual interventions

4.4. Stage 4: Establishing interpretation and likely impact The final stage seeks to access the views of the target audience. This is likely to involve collecting data (through focus groups or interviews) with members of the target group and relevant health professionals to assess: the understanding and acceptability of the animation; the likelihood of the intervention influencing behaviour as intended; and views of how these images can be modified in order to improve the psychological impact in such a way as to promote behaviour change. The resulting intervention would then require testing within a full experimental design. 4.4.1. HealthForce – worked example We used qualitative methods to gain the perspectives of both 15 future potential patients, and 5 health professionals who might be involved in the delivery of the service. Permission for the study was granted by Tayside Medical Research Ethics Committee. Participants watched the animation as many times as they wished and were informed that they could either use a ‘‘think aloud’’ technique if they desired (i.e. vocalising their thoughts as and when they were watching the animation). An interviewer was also present to record any visible reactions. Immediately after viewing the animation an in-depth interview was conducted. A short in-depth interview then followed. Both patients and health professionals made suggestions for improvements to the intervention. However, there were significant discrepancies in views with regard to interpretation, impact and mechanisms of action. Patients were extremely positive with regard to the intervention and reported few if any problems in understanding or interpreting the animation as a whole or the individual components. There was preliminary evidence that it successfully communicated increased susceptibility, enhanced understanding of mechanisms (coherence) and shifted beliefs from the abstract to the concrete several patients indicated that they already understood what was happening but the at the visual representation ‘‘brought it home’’. There was no evidence to indicate that perceived severity had increased as it appeared high at the outset for all participants. The narrative structure that emphasised understanding mechanisms of action, and the associated visual nature of this, appeared to be particularly important and appreciated. Health professionals, however, tended to believe that the impact would be marginal and implicitly disagree with the underlying theoretical components. Instead they suggested that understanding mechanisms was less important and that more emphasis should be placed on severity of outcome, and perhaps make this more graphic. 5. Discussion: limitations and future methodological and ethical considerations Our documented experience during the course of developing this animation has led to a possible framework

The model shown in Fig. 1 represents diagrammatically the processes that we engaged in throughout the development of the intervention, along with suggestions for how to operationalise each step. As with the MRC Framework this model and its constituent elements ‘‘should not be read as an inflexible ‘‘to do list’’, but rather as advice to apply to the extent to which it is relevant at each stage of your own research.’’ (Medical Research Council, 2000, p. 3). We hope not only that this model may aid development but may also aid structured reporting and allow social and behavioural scientists to share knowledge and practical lessons learnt during each of these stages. The model reflects the outcome of the iterative process established in this research. However, it also goes further in order to point to lessons learnt. For example, we would suggest greater involvement of patients from an earlier stage, coupled to a clear initial exploration of pre-existing qualitative work that provides an insight into patient opinion and conceptualisations of the body and or illness. 5.2. Limitations of the model We do not suggest that the model is either complete or sufficiently sophisticated as to guarantee success and applicability in all contexts. In particular, we have concentrated the development of this model on intentional as opposed to non-intentional behaviours; primarily due to the focus of most behaviour change strategies being through informed decision making and empowerment models. However, given the role of images in nonintentional and non-cognitive based behaviour (e.g. response to body language, facial symmetry/beauty, and colour based placebo effect) it is likely that an adapted model covering such behaviours may be beneficial. In addition to this we are aware that three elements are potentially under-developed and require further research. In stage one identifying current relevant theory may, on its own, be insufficient. Collection of new empirical data may be required. Data collected in stage 3 suggested that a number of respondents already had a mental image representing and embodying their own lay perceptions around anatomy, physiology and even pathology. Prior knowledge of these conceptualisations may be helpful in order to identify key inaccurate and potentially unhelpful visual representations that could be addressed through rerepresentations within created animations. There is increasing evidence that patients do have such mental images and that they are accessible (Broadbent et al., 2004a,b, 2006; Harrow et al., 2008a,b; Williams et al., 2007), may draw heavily upon metaphor (Kleinman et al., 1978a,b; Sontag, 2001) and can be highly inaccurate (Boyle, 1970). In stage 2 there are likely to be far more alternatives to the simple narrative evident in our model and animation. In particular we recognise the possibility of multiple narratives may be worth considering, highlighting choice

B. Williams et al. / International Journal of Nursing Studies 49 (2012) 1598–1609

and subsequent outcomes. We would also emphasise the potential that personalisation of animation and narrative may have. The closer that the characteristics of both the narrative and visual forms match those of the viewer the greater the likely impact on risk representations (Cameron, 2003). This has been demonstrated through recent personalised cardiac animations (Lee, 2007) and through studies showing smokers ultrasound images of their own damaged arteries (Shahab et al., 2007). We are also aware that such animation may still potentially incorporate text or spoken word. The various potential relationships between words and the animation also require further consideration. This could draw on current taxonomies developed in other academic areas (Mendelson et al., 2003). In stage 3 the optimum process by which theory and concepts can be embodied in visual or audible form is far from clear. Our search for relevant theory and empirical evidence led to numerous academic disciplines each with its own concepts, theory and language. We refer here to colour theory, semiotics, aesthetics, iconography and computer based art. However, on closer examination it became clear that many of ideas and concepts contained within these disciplines overlapped and yet there was little evidence through cross referencing of inter-disciplinary dialogue. There is a clear need for a fuller mapping out of these theories, their inter-relationship and supporting evidence base in order to avoid future people working in this applied area spending vast amounts of time exploring multiple academic avenues and discovering dead-ends. Such a mapping may aid development of common terminology and keywords thus improving the efficiency of literature searching and retrieval in this context. 5.3. Methodological, practical and ethical considerations If concreteness through the use of visual images and increased sensory engagement can have a powerful impact on experience, attitude, intention and behaviour then researchers must consider the following ethical questions. In what contexts are such interventions ethically and socially unacceptable? Are there potential dangers associated with the use of increasingly concrete imagery? Would images need to be tailored for particular social groups, personality types or cognitive styles? Given that many countries now show photographs of diseased lungs on tobacco packs we might envisage moving further towards even greater ‘‘concreteness’’ and allowing smokers to see and even feel diseased and healthy organs in real life. Theoretically, such techniques may have increased impact. However, it is also possible that at some point such concreteness may prove so powerful as to be harmful, promoting excessive rumination, intrusive images and ongoing anxiety (Hackmann et al., 1998; Olatunji et al., 2005). It is possible that more detailed research to examine and quantify these potential dangers may provide sufficient information as to be able to modify such images or experience to minimise harm, or to be able to tailor images appropriately for different audiences with varied cognitive styles.

1607

Even if harm can be minimised visual interventions may still remain open to wider scrutiny within regulatory frameworks in different countries. For example, most countries have formal bodies that monitor advertising standards; visual interventions publically displayed via poster or television would fall within their remit. In the UK, such images would have to comply with the Advertising Standards Authority (ASA) rules, which reflect five key principles: they should not mislead, cause serious or widespread offence, cause harm, they must be socially responsible and have regard for the principles of fair competition. Some of these elements will require careful consideration by intervention developers. Even if researchers can produce empirical evidence to support the non-existence of harm, predicting subsequent ‘‘serious or widespread offence’’ may be more difficult. For example, in 2007 the UK Department of Health antismoking campaign used a visual metaphor which featured people with fish hooks in their mouths. This led to 774 complaints to the ASA that it was offensive, frightening and distressing causing it to top the ASA complaints ranking during that year. The complaint was upheld on the basis that it was untargeted, and realistically and graphically showed the piercing of the cheek with a hook, and were likely to frighten and distress children (ASA, 2007). This suggests, however, that more targeted age-specific interventions may still be acceptable. ASA guidance also suggests that visual animation should not mislead. However, in order to convey a key message some aspects of visual depictions will not necessarily correspond to reality. For example, a cardiac intervention might show a heart moving from a healthy pink colour to a green/grey hue in order to communicate a shift from healthy to unhealthy heart. In reality such a colour change may not take place. While the visual cue may not be true to life the message it communicates is. Is this misleading and unethical and does it push the animation over the fine line that separates legitimate persuasion (Lester, 2003) from value-laden propaganda? Answers to these questions are currently unclear although they have been negotiated in other areas, notably marketing research (Schroeder and Borgerson, 2005), and lessons may be learnt from this discipline. For the moment it would at least seem sensible to ensure that recipients of such interventions are informed that pictures and moving animations are representations rather than a strict true-tolife depiction. 6. Conclusion We believe that given an increasing social preference for visual forms of communication there is a need to develop the evidence base and identify relevant theory to support behavioural interventions that use such media. Relevant theory and some empirical evidence does exist although it is currently dispersed across a range of academic disciplines, is not at present conclusive, and is employed for diverse purposes and contexts. The model proposed is an initial attempt to provide a framework for development and may provide starting point for others working in this area. We hope that this may prove the basis

1608

B. Williams et al. / International Journal of Nursing Studies 49 (2012) 1598–1609

for increased inter-disciplinary dialogue and the subsequent creation of visual interventions that have increased effectiveness and acceptability. Conflict of interest None. Funding UK National Prevention Research Initiative (NPRI): funding was provided and peer review on the proposal but no influence over conduct beyond that. Ethical approval Tayside and Forth Valley Research Ethics Committee.

References Abraham, C., Michie, S., 2008. A taxonomy of behavior change techniques used in interventions. Health Psychology 27 (3), 379–387. ASA, 2007. Annual Report. Advertising Standards Authority, London. Ausburn, L., Ausburn, F., 1978. Visual literacy: background, theory and practice. PLET 15 (4), 291–297. Avgerinou, M., Ericson, J., 1997. A review of the concept of visual literacy. British Journal of Educational Technology 28 (4), 280–291. Bandura, A., 1977. Self-efficacy: toward a unifying theory of behavioural change. Psychological Review 84, 191–215. Becker, M.H., Maiman, L.A., Kirscht, J.P., Haefner, D.P., Drachman, R.H., 1977. The Health Belief Model and prediction of dietary compliance: a field experiment. Journal of Health and Social Behavior 18 (4), 348– 366. Boyle, C.M., 1970. Differences between patients’ and doctors’ interpretation of some common medical terms. British Medical Journal 2, 286– 289. Bradley, M.M., Lang, P.J., 1999. Fearfulness and affective evaluations of pictures. Motivation and Emotion 23 (1). Broadbent, E., Ellis, C.J., Gamble, G., Petrie, K.J., 2006. Changes in patient drawings of the heart identify slow recovery after myocardial infarction. Psychosomatic Medicine 68, 910–913. Broadbent, E., Petrie, K., Ellis, C., Ying, J., Gamble, G., 2004a. A picture of health – myocardial infarction patients’ drawings of their hearts and subsequent disability: a longitudinal study. Journal of Psychosomatic Research 57, 583–587. Broadbent, E., Petrie, K.J., Ellis, C.J., Ying, J., Gamble, G., 2004b. A picture of health – myocardial infarction patients’ drawings of their hearts and subsequent disability. A longitudinal study. Journal of Psychosomatic Research 57, 583–587. Cameron, L., 2003. Conceptualizing and assessing risk perceptions: a selfregulatory perspective. In: Conceptualizing and Measuring Risk Perception Workshop, Washington, DC. Campbell, S., Reading, A.E., Cox, D.N., Sledmore, C.M., Mooney, R., Chudleigh, P., Beedle, J., Ruddick, H., 1982. Ultrasound scanning in pregnancy: the short-term psychological effects of early real-time scans. Journal of Psychosomatic Obstetrics and Gynaecology 1 (2), 57–61. Carver, C.S., Sutton, S.K., Scheier, M.F., 2000. Action, emotion, and personality: emerging conceptual integration. Personality and Social Psychology Bulletin 26, 741–751. Chandler, D., 2007. Semiotics: The Basics. Routledge, London. Coster, S., Norman, I., 2009. Cochrane reviews of educational and selfmanagement interventions to guide nursing practice: a review. International Journal of Nursing Studies 46, 508–528. Craig, P., Dieppe, P., MacIntyre, S., Michie, S., Nazareth, I., Petticrew, M., 2008. Developing and evaluating complex interventions: new guidance. Medical Research Council 1–39. Craigie, A.M., Barton, K.L., MacLeod, M., Williams, B., Teijlingen, E.V., Belch, J.F., Anderson, A.S., 2011. A feasibility study of a personalised lifestyle programme (HealthForce) for individuals who have participated in cardiovascular risk screening. Preventive Medicine. Damasio, A.R., 1994. Descarte’s Error: Emotion Reason and the Human Brain. Avon, New York. DeWalt, D.A., Berkman, N.D., Sheridan, S., Lohr, K.N., Pignone, M.P., 2004. Literacy and health outcomes: a systematic review of the literature. Journal of General Internal Medicine 19, 1228–1239. Diefenbach, M.A., Miller, S., Daly, M., 1999. Specific worry about breast cancer predicts mammography use in women at risk for breast and ovarian cancer. Health Psychology 18, 532–536.

Dykes, K., Stjernqvist, K., 2001. The importance of ultrasound to first-time mothers’ thoughts about their unborn child. Journal of Reproductive and Infant Psychology 19 (2), 95–104. Edworthy, J., Loxley, S., Dennis, I., 1991. Improving auditory warning design: relationship between warning sound parameters and perceived urgency. Human Factors 33 (2), 205–231. Epstein, S., 1994. Integration of the cognitive and the psychodynamic unconscious. American Psychologist 49, 709–724. Gagliano, M.E., 1988. A literature review on the efficacy of video in patient education. Journal of Medical Education 63, 785–792. Gardner, M.P., Houston, M.J., 1986. The effects of verbal and visual components of retail communications. Journal of Retailing 62, 64–78. Glasgow, R.E., Mckay, H.G., Piette, J.D., Reynolds, K.D., 2001. The RE-AIM framework for evaluating interventions: what can it tell us about approaches to chronic illness management? Patient Education and Counselling 44, 119–127. Goncalves, O.F., Machado, P.P.P., 1999. Cognitive narrative psychotherapy. Journal of Clinical Psychology 55, 1179–1191. Gray, J.R., 1999. A bias towards short-term thinking in threat-related negative emotional states. Personality and Social Psychology Bulletin 25, 65–75. Gray, J.R., 2001. Emotional modulation of cognitive control: approachwithdrawl states double-dissociate spatial from verbal two-back task performance. Journal of Experimental Psychology: General 130, 436– 452. Greenhalgh, T., 1998. Outside the ivory towers: evidence based medicine in the real world. British Journal of General Practice 48, 1448–1449. Guillemin, M., 2004. Understanding illness: using drawings as a research method. Qualitative Health Research 14 (2), 272–289. Hackmann, A., Surawy, C., Clark, D.M., 1998. Seeing yourself through others’ eyes: a study of spontaneously occurring images in social phobia. Behavioural and Cognitive Psychotherapy 26, 3–12. Hagger, M.S., Orbell, S., 2003. A meta-analytic review of the commonsense model of illness representations. Psychology & Health 18 (2), 141–184. Hall, S., Weinman, J., Marteau, T.M., 2004. The motivating impact of informing women smokers of a link between smoking and cervical cancer: the role of coherence. Health Psychology 23 (4), 419–424. Harrow, A., Wells, M., Humphris, G., Taylor, C., Williams, B., 2008a. ‘‘Seeing is believing, and believing is seeing’’: an exploration of the meaning and impact of women’s mental images of breast cancer and their origin in health care communications. Patient Education and Counseling 73 (2), 339–346. Harrow, A., Wells, M., Humphris, G., Taylor, C., Williams, B., 2008b. ‘‘Seeing is believing, and believing is seeing’’: an exploration of the meaning and impact of women’s mental images of their breast cancer and their potential origins. Patient Education and Counseling 73 (2), 339–346. Healton, C.G., Messeri, P., 1993. The effect of video interventions on improving knowledge and treatment compliance in the sexually transmitted disease clinic setting: lessons for HIV health education. Sexually Transmitted Diseases 20, 70–76. Helman, C.G., 1998. Culture Health and Illness. Butterworth-Heinemann, Oxford. Helman, C.G., 1985. Disease and pseudo-disease: a case history of pseudo angina. In: Hahn, R.A., Gaines, A.D. (Eds.), Physicians of Western Medicine: Anthropological Approaches to Theory and Practice. Reidel, Dordrecht, pp. 293–331. Helman, C.G., 1978. ‘‘Feed a cold starve a fever’’ – folk models of infection in an English suburban community, and their relation to medical treatment. Culture, Medicine and Psychiatry 2, 107–137. Israel, G.D., 2006. Using Logic Models for Program Development. University of Florida, Gainesville. Ito, T.A., Cacioppo, J.T., Lang, P.J., 1998. Eliciting affect using the international affective picture system: trajectories through evaluative space. Personality and Social Psychology Bulletin 24 (8), 855–880. Jarlais, D.C.D., Lyles, C., Crepaz, N., Group, T., 1994. Improving the reporting quality of nonrandomized evaluations of behavioral and public health interventions: The TREND Statement. American Journal of Public Health 4 (3), 361–366. Jekosch, U., 2005. Assigning meaning to sounds – semiotics in the context of product-sound design. Communication Accoustics 193–221. Kershaw, S., Newton, J.T., Williams, D.M., 2008. The influence of tooth colour on the perceptions of personal characteristics among female dental patients: comparisons of unmodified, decayed and ‘whitened’ teeth. British Dental Journal 204 (5), E9. Kleinman, A., 1988. The Illness Narratives. Basic Books, New York. Kleinman, A., Eisenberg, L., Good, B., 1978a. Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine 88, 251–258.

B. Williams et al. / International Journal of Nursing Studies 49 (2012) 1598–1609 Kleinman, A., Eisenberg, L., Good, B., 1978b. Clinical lessons from anthropological and cross-cultural research. Annals of Internal Medicine 88, 251–258. Krouse, H.J., 2001. Video modelling to educate patients. Journal of Advanced Nursing 33 (6), 748–757. Kulkofsky, S., Wang, Q., Ceci, S.J., 2008. Do better stories make better memories? Narrative quality and memory accuracy in preschool children. Applied Cognitive Psychology 22, 21–38. Lang, H., Harrow, A., Humphris, G., Taylor, C., Wells, M., Williams, B., 2007. The role of mental images in illness behaviour and self-care. Alliance for Self Care Newsletter 2 (1), 1–2. Langer, M., Ringler, M., Reinold, E., 1988. Psychological effects of ultrasound examinations: changes of body perception and child image in pregnancy. Journal of Psychosomatic Obstetrics and Gynaecology 8 (3), 199–208. Lee, T., 2007. Preventive Health Messages for Cardiovascular Disease: The Role of Abstract Text and Concrete Animation. Department of Psychology, University of Auckland, Auckland. Lee, T.J., Cameron, L.D., Wu¨nsche, B., Stevens, C., 2011. A randomized trial of computer-based communications using imagery and text information to alter representations of heart disease risk and motivate protective behaviours. British Journal of Health Psychology 16 (1), 72–91. Lelie, C.V.D., 2005. The value of storyboards in the product design process. Personal and Ubiquitous Computing 10 (2–3), 159–162. Lester, P.M., 2003. Visual persuasion in advertising, public relations and journalism. In: Lester, P.M. (Ed.), Visual Communication: Images with Messages. Wadsworth Thomson, Belmont, pp. 63–87. Leventhal, H., Meyer, D., Nerenz, D., 1980. The common sense representation of illness danger. In: Rachman, S. (Ed.), Medical Psychology. Pergamon, New York, pp. 7–30. Leventhal, H., Nerenz, D., 1985. The assessment of illness cognition. In: Karoly, P. (Ed.), Measurement Strategies in Health Psychology. John Wiley, New York, pp. 517–554. Luciani, A., Urma, D., Marliere, S., Chevrier, J., 2004. PRESENCE: the sense of believability of inaccessible worlds. Computers & Graphics 509–517. Mabeck, C.E., Olesen, F., 1997. Metaphorically transmitted disease. How do patients embody medical explanations? Family Practice 14 (4), 271–278. Macdonald, W., Rogers, A., Blakeman, T., Bower, P., 2008. Practice nurses and the facilitation of self-management in primary care. Journal of Advanced Nursing 62 (2), 191–199. Medical Research Council, 2000. A Framework for Development and Evaluation of RCTs for Complex Interventions to Improve Health. . Mendelson, A.L., Thorson, E., Marsh, E.E., Domas-White, M., 2003. A taxonomy of relationships between images and text. Journal of Documentation 59 (6), 647. Michie, S., 2008. What works and how? Designing more effective interventions needs answers to both questions. Addiction 103, 886–892.

1609

Michie, S., Abraham, C., 2004. Interventions to change health behaviours: evidence-based or evidence-inspired. Psychology & Health 19 (1), 29–49. Moriarty, S., 1995. Visual Semiotics and the Production of Meaning in Advertising. Visual Communication Division of the AEJMC, Washington. Moss-Morris, R., Weinman, J., Petrie, K.J., Horne, R., Cameron, L.D., Buick, D., 2002. The revised illness perception questionnaire (IPQ-R). Psychology & Health 17 (1), 1–16. Olatunji, B.O., Williams, N.L., Lohir, L.M., Sawchuk, C.N., 2005. The structure of disgust: domain specificity in relation to contamination ideation and excessive washing. Behaviour Research and Therapy 43, 1069–1086. Paivio, A., Walsh, M., Bons, T., 1994. Concreteness effects on memory: when and why? Journal of Experimental Psychology: Learning, Memory and Cognition 20 (5), 1196–1204. Prabu, D., 1998. News concreteness and visual–verbal association: do news pictures narraow the recall gap between concrete and abstract news. Human Communication Research 25 (2), 180–201. Radley, A., 1999. The aesthetics of illness: narrative, horror and the sublime. Sociology of Health & Illness 21 (6), 778–796. Schroeder, J.E., Borgerson, J.L., 2005. An ethics of representation for international marketing communication. International Marketing Review 22 (5), 578–600. Shahab, L., Hall, S., Marteau, T., 2007. Showing smokers with vascular disease images of their arteries to motivate cessation: a pilot study. British Journal of Health Psychology 12 (2), 275–283. Slovic, P., Finucane, M.L., Peters, E., MacGregor, D., 2003. Risk as analysis and risk as feelings: some thoughts about affect, reason, risk and rationality. In: Conceptualizing and Measuring Risk Perceptions, National Cancer Institute, New York. Sontag, S., 1978. Illness as Metaphor. Vintage, New York. Sontag, S., 2001. Illness as Metaphor and AIDS and its Metaphors. Picador, New York. Steckler, A., McLeroy, K.R., 2008. The importance of external validity. American Journal of Public Health 98 (1), 9–10. van Leeuwen, T., 2005. Introducing Social Semiotics. Routledge, London. van Leeuwen, T., 2001. Semiotics and iconography. In: van Leeuwen, T., Jewitt, C. (Eds.), The Handbook of Visual Analysis. Sage, London, pp. 92–118. Williams, B., Cameron, L., 2009. The potential and problems of the increasing use of images in health care interventions: are we running before we can walk? Journal of Health Services Research & Policy 14 (4), 251–254. Williams, B., Mukhopadhyay, S., Dowell, J., Coyle, J., 2007. Problems and solutions: accounts by parents and children of adhering to chest physiotherapy for cystic fibrosis. Disability & Rehabilitation 29 (14), 1087–1105.