Abstract
Objective
To assess the effects of pictures on health communications.
Method
Peer reviewed studies in health education, psychology, education, and marketing journals were reviewed. There was no limit placed on the time periods searched.
Results
Pictures closely linked to written or spoken text can, when compared to text alone, markedly increase attention to and recall of health education information. Pictures can also improve comprehension when they show relationships among ideas or when they show spatial relationships. Pictures can change adherence to health instructions, but emotional response to pictures affects whether they increase or decrease target behaviors. All patients can benefit, but patients with low literacy skills are especially likely to benefit. Patients with very low literacy skills can be helped by spoken directions plus pictures to take home as reminders or by pictures plus very simply worded captions. Practice implications: Educators should: (1) ask “how can I use pictures to support key points?”, (2) minimize distracting details in pictures, (3) use simple language in conjunction with pictures, (4) closely link pictures to text and/or captions, (5) include people from the intended audience in designing pictures, (6) have health professionals plan the pictures, not artists, and (7) evaluate pictures’ effects by comparing response to materials with and without pictures.
Introduction
Communication between health professionals and patients is inherently problematic. Professionals want to communicate clearly, but tend to use technical terminology because it is precise, because it is familiar, and often because there are no exactly equivalent non-technical words available. Furthermore, they often try to communicate more information than patients can process. Patients, even those with well developed language skills, find it difficult to process medical information because they are unfamiliar with medical terminology, because they are preoccupied with their symptoms, and because they are upset which makes concentration difficult.
While people at all literacy levels have problems understanding and using health information, people with limited literacy skills are especially in need of help. They need help in understanding written information and, because they place more reliance on spoken explanations, they need help in remembering what they hear.
This paper discusses how combining pictures with spoken or written text affects health communication. Four aspects of health communication will be discussed: (1) drawing attention to the materials or message, (2) helping people comprehend the information being presented, (3) increasing recall of the message, and (4) increasing the likelihood that people will act in accordance with the message (adherence). This paper reviews research on how pictures combined with text can affect each of these aspects and also makes recommendations for how health educators can use pictures most effectively.
Our work is closely related to McGuire's information processing theory [1] in which he proposed a matrix to explain the communication/persuasion process. His matrix consists of five input variables (source, message characteristics, channel, receiver and response target) and thirteen output variables (exposure, attention, liking, comprehension, cognitive elaboration, skill acquisition, agreement, memory, retrieval, decision making, acting on the decision, cognitive consolidation, and proselytizing). Pictures fall within McGuire's second input variable “message characteristics,” while four of McGuire's output variables, attention, comprehension, memory, and acting on the decision relate directly to our four presentation elements (attention, comprehension, recall, and adherence.) McGuire's model is a useful conceptual framework for our literature review because it positions pictures within the persuasion process. It also suggests directions for future research on how pictures can contribute to health education. For example, his list of output variables points to additional ways in which pictures could contribute to health education that have not been studied by health education researchers. The theory also calls attention to possible interactions among output variables. In the discussion section of this paper we will utilize McGuire's theory in discussing future research directions.
In addition to reviewing published studies, we will propose hypotheses to guide both researchers and practitioners in planning future programs. At the end of this paper we also make recommendations for how health educators can make optimum use of pictures. These hypotheses and recommendations are based on the literature review and the authors’ experiences in developing and reviewing illustrated health education materials.
Our goals are to:
(1)provide quantitative data on how the addition of pictures to text affects health communication;
(2)provide quantitative data on how pictures affect different populations, especially minority and people with low literacy skills;
(3)identify areas where more research is needed;
(4)make recommendations for how health educators can make optimal use of pictures in combination with text.
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