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Effective use of patient education illustrations
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Patient Education and Counseling. 15(1990) 13-15 Elsevier Scientific Publishers Ireland Ltd.
Management Rounds
Effective use of Patient Education Linda
Rohreta
Illustrations*
and Kristi J. Fergusonb
“MedicalMedia Production Service, High way 6 West, Veterans Administration Hospital (142B), Iowa City, IA 52246 and bUniversity of Iowa College of Medicine, 2351 Steindler Building, Iowa City, IA 52242 (USA) (Received September 7th, 1989) (Accepted September 13th, 1989)
Abstract
Effective illustrations can greatly enhance patient education materials, yet many illustrations do not aid instruction as much as they could. By following the above recommendations, patient education materials developers and illustrators can together accomplish their objectives. Patient education; Instructional design.
Keywords:
Illustrations;
Introduction
It has been said that a picture is worth a thousand words. A better way to say it for patient education may be: the appropriate picture is worth a thousand words. Empirical evidence suggests that learners benefit from various forms of pictorial representations. For example, studies have shown that learners with illustrated material performed procedures better [ 1,2] and had better recall [3-61. Having materials that are attractively presented, easy to understand and interesting to read can increase interest and thereby L. Rohret, Medical Illustrator K. J . Ferguson, Associate Research Scientist. *An earlier version of this paper was presented at the Health Sciences Communication Association annual meeting in St. Louis, MO, April, 1989.
improve learning. Simple line drawings, graphics, or diagrams can help make a complex idea or procedure more easily underConsiderations effective stood. for illustrations include the size of illustrations, labeling, and use of color to enhance the learning process. Dwyer has suggested that indiscriminate use of illustrations reflects a belief that one type of illustration is as good as another [7]. Dwyer notes that inappropriate illustrations can confuse rather than help the learner if they are not linked to the educational purpose. Unfortunately, many patient education drawings are based on the subjective feelings of the designer about what is best, on the accessibility of raw information, the availability of materials, the cost, the attractiveness of the finished product, and the availability of a ready market, rather than on an educational purpose. Methods
The purpose of the project was to develop recommendations for illustrators who are asked to draw illustrations for patient education materials. We selected 45 patient education handouts from several sources, including for-profit educational companies (19 booklets), drug companies (5 booklets), voluntary health organizations (12 booklets) and hospi-
0738-3991/90/$03.50 0 1990 Elsevier Scientific Publishers Ireland Ltd. Published and Printed in Ireland
tals, medical organizations or government organizations (9 booklets). Each contained at least one illustration. Booklets covered a range of diagnoses, such as heart disease, breast exam, urologic difficulties, bronchitis and osteoporosis. The median number of pages was eight and the median number of words was about 1200. Based on a review of literature regarding illustrating patient education materials, we developed a checklist used to review a total of 45 booklets. Criteria included the following: (1) Necessity: Was the drawing itself necessary to convey the educational goals of the booklet? Did it add to the patient’s ability to understand the text? (2) Suitability to convey content: Did the drawing contain too much information to be helpful? Was it the correct type of drawing to convey the content? (3) Familiarity to patients: Would patients recognize the drawing and be able to locate what was being shown in the body? (4) Overall layout: Was the size, print, empty space, and color appropriate for the concept being conveyed? (5) Single concept: Did the drawing convey a single concept or idea? (6) Size: Was the drawing itself sized appropriately for the type of booklet, type of text, and the concept itself? (7) Lines: Were the lines heavy enough to be seen? (8) Labeling: Was the size of print large enough relative to the drawing? (9) Distracting elements: Were ideas not relevant to the educational purpose eliminated? One of the authors (LR), who is an illustrator herself, reviewed each booklet and assigned a rating (1 = very good to 5 = very poor) to the booklets in each of the categories. Results
In general, very few of the illustrations reviewed received high ratings in all catego-
ries. The criterion met most often was necessity of an illustration, which received an average rating of 2.0. However, even for necessity only 14 out of 46 received the best rating of 1. The next best criterion was that the drawing illustrated a single concept (average rating = 2. I), though again only 13 drawings received the highest rating. Overall layout and distracting elements eliminated received intermediate ratings (average ratings of 2.6 and 2.7), as did the size of lines and the size of print (average ratings of 2.7 and 2.8, respectively). The areas in which most illustrations reviewed needed most improvement were labeling (average rating = 3.0), suitability to convey content (average rating = 3. l), and familiarity to patient (average rating = 3.3). Discussion
While using pre-existing printed patient education materials may be less expensive and less time-consuming than preparing one’s own, many patient educators must develop their own materials because they have special needs for which appropriate materials are not available. Docherty wrote that trying to promote health education in this very sophisticated visual world is becoming increasingly an applied science [8]. Docherty concluded that while the continued partnership between health educators and medical illustrators can produce excellent material, included within this partnership must be a shared understanding of the instructional design process. For example, patient education developers must keep in mind that traditional medical illustrators are accustomed to drawing for medical students and that the artistic flair and shading that add to a drawing’s appearance and are characteristic of medical illustrations may not be necessary for patients, and may in fact be distracting. The overall layout of a drawing or a group of drawings can enhance or detract from learning as well. If drawings are too small and/or lettering or labeling are too small, a
75
patient may have difficulty seeing and thereby simply pass over the visual information. The proper use of empty or filled space is critical - if space is filled simply to add background, the patient may be distracted from the central theme of the drawing. On the other hand, too much empty space around the central theme may cause the patient to dismiss the drawing. Color should be used primarily to enhance an area or to distinguish one area from another. While color should not be garish, pastels are often too light to make an impact. An awareness of the learner’s age will influence various aspects of the overall layout, e.g. drawings intended primarily for elderly patients will need to be larger and even less cluttered than may be necessary for younger learners. Recommendations for patient educators Educational developers who are considering using illustrations should consider the following recommendations. Most importantly, make sure that the illustration serves an educational purpose. Decide first what purpose the handout itself serves and then ask what illustration(s) would help accomplish that purpose. Then convey that purpose to the illustrator with instructions to keep the drawing as simple as possible. Make sure the illustration is clearly labeled and that it conveys only one idea at a time. Finally, pilot test any illustrated booklets before you publish them. Ask prospective readers whether the drawings were understandable, whether the letters and drawings were the right size, and whether the reader has any additional comments. Recommendations for patient education illustrators Patient education illustrators should consider the following recommendations. Most
importantly, ask the booklet developer what the illustration(s) will do to help accomplish the overall purpose of the patient education materials. As you draw, remember to save artistic flourishes for commercial art: for patient education, the simpler the better. Next, locate any anatomical parts in the body. For example, if you are illustrating a total hip replacement, show how the joint replacement is positioned within the body and how it relates to other body parts. Be sure that labels use terms that are familiar to the patient, for example, thigh bone rather than femur, kneecap rather than patella. Next, regarding administrative details; ask ahead of time how much money is available for the illustrations and whether they will be in black and white or color. Find out what printer will be printing the document and how it will be done. Find out who will prepare the text and ask the individual where the illustrations fit within the overall purpose of the booklet. Finally, develop timelines for your work that correspond with the deadlines established by the educational developer. References Bender CM et al: Patient teaching in hepatic artery infusion. Oncology Nsg Forum 1984; 11: 61-65. Spindler CE: Audiovisual preoperative teaching for the total hip patient. Orthopaedic Nurs 1984; 3: 30-40. Harden RM: A new approach to the design of instructional text. J Audiovisual Media Med 1983; 6: 124-129. Komisarz JM: Chondromalacia patella. Orthopaedic Nurs 1984; 3: 24-28. Reed LA, Hoffman LG: Pictorial cues and enhancement of patient recall of instructions or information. J Am Optometric Assoc1986; 57: 312-315. Moll JMH: Doctor-patient communication in rheumatology: studies of visual and verbal perception using educational booklets and other graphic material. Ann Rheum Dis 1986; 45: 198-209. Dwyer FM: A Guide for Improving Visualized Instruction. State College, PA: Learning Services, 1972. Docherty SC: Communication means more than pretty pictures. J Audiovisual Media Med 1983; 6: 137-139.
Patient Education and Counseling. 15(1990) 13-15 Elsevier Scientific Publishers Ireland Ltd.
Management Rounds
Effective use of Patient Education Linda
Rohreta
Illustrations*
and Kristi J. Fergusonb
“MedicalMedia Production Service, High way 6 West, Veterans Administration Hospital (142B), Iowa City, IA 52246 and bUniversity of Iowa College of Medicine, 2351 Steindler Building, Iowa City, IA 52242 (USA) (Received September 7th, 1989) (Accepted September 13th, 1989)
Abstract
Effective illustrations can greatly enhance patient education materials, yet many illustrations do not aid instruction as much as they could. By following the above recommendations, patient education materials developers and illustrators can together accomplish their objectives. Patient education; Instructional design.
Keywords:
Illustrations;
Introduction
It has been said that a picture is worth a thousand words. A better way to say it for patient education may be: the appropriate picture is worth a thousand words. Empirical evidence suggests that learners benefit from various forms of pictorial representations. For example, studies have shown that learners with illustrated material performed procedures better [ 1,2] and had better recall [3-61. Having materials that are attractively presented, easy to understand and interesting to read can increase interest and thereby L. Rohret, Medical Illustrator K. J . Ferguson, Associate Research Scientist. *An earlier version of this paper was presented at the Health Sciences Communication Association annual meeting in St. Louis, MO, April, 1989.
improve learning. Simple line drawings, graphics, or diagrams can help make a complex idea or procedure more easily underConsiderations effective stood. for illustrations include the size of illustrations, labeling, and use of color to enhance the learning process. Dwyer has suggested that indiscriminate use of illustrations reflects a belief that one type of illustration is as good as another [7]. Dwyer notes that inappropriate illustrations can confuse rather than help the learner if they are not linked to the educational purpose. Unfortunately, many patient education drawings are based on the subjective feelings of the designer about what is best, on the accessibility of raw information, the availability of materials, the cost, the attractiveness of the finished product, and the availability of a ready market, rather than on an educational purpose. Methods
The purpose of the project was to develop recommendations for illustrators who are asked to draw illustrations for patient education materials. We selected 45 patient education handouts from several sources, including for-profit educational companies (19 booklets), drug companies (5 booklets), voluntary health organizations (12 booklets) and hospi-
0738-3991/90/$03.50 0 1990 Elsevier Scientific Publishers Ireland Ltd. Published and Printed in Ireland
tals, medical organizations or government organizations (9 booklets). Each contained at least one illustration. Booklets covered a range of diagnoses, such as heart disease, breast exam, urologic difficulties, bronchitis and osteoporosis. The median number of pages was eight and the median number of words was about 1200. Based on a review of literature regarding illustrating patient education materials, we developed a checklist used to review a total of 45 booklets. Criteria included the following: (1) Necessity: Was the drawing itself necessary to convey the educational goals of the booklet? Did it add to the patient’s ability to understand the text? (2) Suitability to convey content: Did the drawing contain too much information to be helpful? Was it the correct type of drawing to convey the content? (3) Familiarity to patients: Would patients recognize the drawing and be able to locate what was being shown in the body? (4) Overall layout: Was the size, print, empty space, and color appropriate for the concept being conveyed? (5) Single concept: Did the drawing convey a single concept or idea? (6) Size: Was the drawing itself sized appropriately for the type of booklet, type of text, and the concept itself? (7) Lines: Were the lines heavy enough to be seen? (8) Labeling: Was the size of print large enough relative to the drawing? (9) Distracting elements: Were ideas not relevant to the educational purpose eliminated? One of the authors (LR), who is an illustrator herself, reviewed each booklet and assigned a rating (1 = very good to 5 = very poor) to the booklets in each of the categories. Results
In general, very few of the illustrations reviewed received high ratings in all catego-
ries. The criterion met most often was necessity of an illustration, which received an average rating of 2.0. However, even for necessity only 14 out of 46 received the best rating of 1. The next best criterion was that the drawing illustrated a single concept (average rating = 2. I), though again only 13 drawings received the highest rating. Overall layout and distracting elements eliminated received intermediate ratings (average ratings of 2.6 and 2.7), as did the size of lines and the size of print (average ratings of 2.7 and 2.8, respectively). The areas in which most illustrations reviewed needed most improvement were labeling (average rating = 3.0), suitability to convey content (average rating = 3. l), and familiarity to patient (average rating = 3.3). Discussion
While using pre-existing printed patient education materials may be less expensive and less time-consuming than preparing one’s own, many patient educators must develop their own materials because they have special needs for which appropriate materials are not available. Docherty wrote that trying to promote health education in this very sophisticated visual world is becoming increasingly an applied science [8]. Docherty concluded that while the continued partnership between health educators and medical illustrators can produce excellent material, included within this partnership must be a shared understanding of the instructional design process. For example, patient education developers must keep in mind that traditional medical illustrators are accustomed to drawing for medical students and that the artistic flair and shading that add to a drawing’s appearance and are characteristic of medical illustrations may not be necessary for patients, and may in fact be distracting. The overall layout of a drawing or a group of drawings can enhance or detract from learning as well. If drawings are too small and/or lettering or labeling are too small, a
75
patient may have difficulty seeing and thereby simply pass over the visual information. The proper use of empty or filled space is critical - if space is filled simply to add background, the patient may be distracted from the central theme of the drawing. On the other hand, too much empty space around the central theme may cause the patient to dismiss the drawing. Color should be used primarily to enhance an area or to distinguish one area from another. While color should not be garish, pastels are often too light to make an impact. An awareness of the learner’s age will influence various aspects of the overall layout, e.g. drawings intended primarily for elderly patients will need to be larger and even less cluttered than may be necessary for younger learners. Recommendations for patient educators Educational developers who are considering using illustrations should consider the following recommendations. Most importantly, make sure that the illustration serves an educational purpose. Decide first what purpose the handout itself serves and then ask what illustration(s) would help accomplish that purpose. Then convey that purpose to the illustrator with instructions to keep the drawing as simple as possible. Make sure the illustration is clearly labeled and that it conveys only one idea at a time. Finally, pilot test any illustrated booklets before you publish them. Ask prospective readers whether the drawings were understandable, whether the letters and drawings were the right size, and whether the reader has any additional comments. Recommendations for patient education illustrators Patient education illustrators should consider the following recommendations. Most
importantly, ask the booklet developer what the illustration(s) will do to help accomplish the overall purpose of the patient education materials. As you draw, remember to save artistic flourishes for commercial art: for patient education, the simpler the better. Next, locate any anatomical parts in the body. For example, if you are illustrating a total hip replacement, show how the joint replacement is positioned within the body and how it relates to other body parts. Be sure that labels use terms that are familiar to the patient, for example, thigh bone rather than femur, kneecap rather than patella. Next, regarding administrative details; ask ahead of time how much money is available for the illustrations and whether they will be in black and white or color. Find out what printer will be printing the document and how it will be done. Find out who will prepare the text and ask the individual where the illustrations fit within the overall purpose of the booklet. Finally, develop timelines for your work that correspond with the deadlines established by the educational developer. References Bender CM et al: Patient teaching in hepatic artery infusion. Oncology Nsg Forum 1984; 11: 61-65. Spindler CE: Audiovisual preoperative teaching for the total hip patient. Orthopaedic Nurs 1984; 3: 30-40. Harden RM: A new approach to the design of instructional text. J Audiovisual Media Med 1983; 6: 124-129. Komisarz JM: Chondromalacia patella. Orthopaedic Nurs 1984; 3: 24-28. Reed LA, Hoffman LG: Pictorial cues and enhancement of patient recall of instructions or information. J Am Optometric Assoc1986; 57: 312-315. Moll JMH: Doctor-patient communication in rheumatology: studies of visual and verbal perception using educational booklets and other graphic material. Ann Rheum Dis 1986; 45: 198-209. Dwyer FM: A Guide for Improving Visualized Instruction. State College, PA: Learning Services, 1972. Docherty SC: Communication means more than pretty pictures. J Audiovisual Media Med 1983; 6: 137-139.