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Tonks in “Safer by design” report points out that there is a great need for good design for medicine, and more attention should be paid to health care design. “The NHS is seriously out of step with modern thinking and practice with regard to design” (Tonks, A., 2008). Moreover recent studies conducted by Spinillo and Padovani focused on information design aspects in effectiveness of medicine inserts, showed that “deficiencies in typography and confusing visual instructions affect task performance and information comprehension” (Spinillo and Padovani, 2009). Well designed information can be crucial for improving patient-doctor communication and prevent from misinterpretation, which can have serious consequences.
Paling recommends using visual aids wherever possible, to maximize understanding. “Good visual aids can help the viewer to see the risk numbers in context, thus providing information and not just data”. Furthermore he states “For many patients, truly “informed” consent (or indeed “dissent”) is difficult to achieve without visual aids. According to Paling’s studies use of a simple visual aid can also improve the doctor-patient relationship. “When simple visual communication tools are shared between doctor and patient, they offer an opportunity to deepen the bond between them. The closer the doctor-patient partnership, the more likely the patient is to be satisfied” (Paling, J., 2003 also Buetow, S., 1998).
Concluding Paling urges that “more research is needed on how different strategies, particularly use of visual aids, help patients to understand risk. Similar studies have already assessed analogous visual tools such as the Wong-Baker FACES pain rating scale – widely used to help patients communicate their level of pain” (Paling, J., 2003). Furthermore he suggests that research should assess how differences in culture, age, and gender affect patients’ perception of risks. “Few studies have examined how different groups respond to risks of any kind, and no studies seem to have investigated which approaches are the most effective for communicating medical risks to different populations” (Paling, J., 2003).
Figure 1. Wong-Baker Faces Scale
From Wong DL, Hockenberry-Eaton M, Wilson D, Winkelstein ML, Schwartz P: Wong’s Essentials of Pediatric Nursing, 6/e, St. Louis, 2001, P. 1301.
Recently Dartey and colleagues looked at improving communication for patients with chronic pain using affective graphic design; also scales inspired by Wong-Baker faces. Designed leaflets concerned patients with low literacy skills and intended to aid accurate timing for medication taking.
According to Dartey’s research “using visual metaphors to facilitate healthcare communication to low-literacy patients stimulates the mind and aids adherence, however, it requires verbal explanation from the health professionals. It should also be developed in collaboration with the target community taking into account their cultural settings” (Dartey et al., 2009).
Figure 2. UCSF Computer generated medication calendar (UCSF TODAY 2007)
Machtinger and colleagues present the success of a visual system implemented by UCSF research team in America. This new visual system creates a weekly computer generated calendar for patients on medication allowing them to see what medication they need to take and how much on a daily basis. Patients receive also written instructions in English and in their native language (Fig 2). The system aims to prevent miscommunication between doctor and patient, allowing the patient to have full understanding of the daily dosage of their medication. A system that concentrated on visual aspects in particular worked well for patients that suffered from memory loss and aided the communication of information to other nationalities. This system created by UCSF supports the use of visual aids to communicate messages to various groups of people, in particular enhancing effective communication across language barriers. Machtinger et all. suggest that visual symbols and use of colour coding can aid doctor-patient communication and improve mutual understanding (Machtinger et all., 2007).
Mansoor and Dowse investigated the effect of pictograms on readability of patient’s information materials. According to the findings of their research presence of pictograms had a positive effect in the acquisition and comprehension of drug information. Moreover participants expressed “an overwhelming positive desire for pictograms in their drug information” (Fig. 3) (Mansoor and Dowse, 2003).
Researchers stressed that in order to stimulate interest; drug information should be user-friendly, attractive, and easily accessible. Evaluating consumer or patient preference through open-ended questions best assesses these features. This form a crucial part of design process of patients information materials This forms a crucial part of the design process of patient information materials as it provides us with valuable information on how to improve the physical appearance and the readability of the leaflets, thereby making the leaflets more comprehensible.
‘Leaflets with the appropriate tone, length, and design can do much to aid responsible medicine taking’ say researchers. According to this study, it was evident that the Z-fold leaflet including pictograms was the preferred format and design (Mansoor and Dowse, 2003).
Figure 3. Nystatin suspension medicine labels (actual size of labels used 4.70 Ã- 7.85 cm) (Mansoor and Dowse, 2003).
The following features successfully contributed to the location and understanding of the information:
1. short, easy-to-read and highlighted headings for navigating through the leaflet;
2. bullet points and broken paragraphs as opposed to solid text for attracting attention;
3. large spaces between paragraphs and important points rendering the leaflet less intimidating; and
4. large print size that improved legibility.
Features that detracted from complete understanding of the information included:
1. the shaded box was ineffective in attracting attention and was often ignored; and
2. the length of the leaflet was a deterrent that sometimes hindered attention span.
(Mansoor and Dowse, 2003).
Suitably designed and tested drug information can ‘improve compliance rates, satisfy patient information needs, and educate patients on the correct use of their medication’ (Mansoor and Dowse, 2003). It also plays an important role in empowering patients to become more active participants in their health care. ‘A more informed patient enables greater participation in the decision-making process, resulting in a positive impact on medicine-taking behavior and health outcomes. It is, therefore, essential that information provided on medicine labels and PILs should be patient oriented, relatively brief, concise, and comprehensive’. (Mansoor and Dowse, 2003).
Review of literature on use of pictorial aids in medication instructions done by Katz and colleagues seams to prove that the use of pictorial aids enhances patients’ understanding of how they should take their medications, particularly when pictures are used in combination with written or oral instructions (Katz et al., 2006). Also Houts and colleagues in their review state that, according to existing research, pictorial aids improve recall, comprehension, and adherence (Houts et al, 2006).
According to their findings there is evidence that people prefer pictures in health messages that are culturally sensitive and include representation of people like themselves and therefore they are more likely to notice these messages. However they couldn’t find any experimental studies which compare attention given to culturally targeted and generic health messages. (Houts et al, 2006).
Houts brings out Levie and Lentz’s research example. They convey study on pictures in education cite which shows, that children prefer stories with pictures to ones without, furthermore audio-visual presentations are considered as more enjoyable and interesting if accompanied with picture (Levie and Lentz’s, 1982). Houts points out that particular audience can respond differently to certain pictures and therefore health educational materials should be first tested with intended audience (Houts et al, 2006).
Delp and Jones study suggests that addition pictures to health education text draws patients attention and will increase the chance that the text will be read.
Leiner et all. research compares non-illustrated leaflet in opposition to a video tape with animated cartoons explaining the need for a polio vaccine. Both the leaflet and video contain the same information. Scores for animated cartoon group were significantly higher than the group with printed information given. Houts et all. reviewing existing studies noted that verbal health information accompanied by pictures helps remember and also recall these information. Houts’ literature search shows that almost all of studies found in educational data base reported that written or spoken text with pictures are better than text alone. This is called the ‘pictorial superiority effect’ in educational research. The effect, according to researchers’ speculation, is caused by greater brain activation evoked by pictures.
However no study was found to prove that the pictorial superiority effect was greater for particular type of content or pictures. Houts et all. stressed that more research is needed, especially on the conditions that maximize pictures’ effects.
Houts gives also useful practice implications for designing the information:
ask ”how can I use pictures to support key points?”,
minimize distracting details in pictures,
use simple language in conjunction with pictures,
closely link pictures to text and/or captions,
include people from the intended audience in designing pictures,
have health professionals plan the pictures, not artists,
evaluate pictures’ effects by comparing response to materials with and without pictures (Houts et al, 2006).
Houts et all. stressed that pictures can ‘change adherence to health instructions, however emotional response to pictures affects whether they increase or decrease target behaviors. The research suggests that 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’ (Houts et al, 2006)
Green and Myers argued that graphic stories and adult themed comics are an innovative and creative way to learn and teach about illness. Juxtaposing text and image can be beneficial especially for people with low literacy skills, learning difficulties; elderly people (Kripalani et al., 2007) can also be helpful in communication with young patients. Powerful visual messages convey immediate visceral understanding in ways that conventional texts cannot say authors (Green and Myers, 2010).
Figure 4 . Cancer Vixen: a personal story of breast cancer
Green and Myers’ research has shown how combining pictures and text enhances understanding, as the activities of reading and viewing activate different information processing systems within the brain. (Mayer R.E., Sims V.K.,1994). ‘This combination also fosters connections between new information and existing knowledge, thereby increasing recall of health information, especially among those with low literacy. This process is even more effective when pictures overlap with text, are explanatory, and are engaging’ (Green and Myers, 2010). Green and Myer say that graphic pathographies can also help patients and their families better understand what to expect of a certain disease (Fig. 4) (Green and Myers, 2010).
Research conducted by Coad and collegues exploited using art-based techniques in engaging children and young people in healthcare. The study looked at how art-based techniques and activities can be applied for use in consultation work and/or research projects with children and young people. In Coad’s research three art-based activities of using photographs, drawings/posters or collages and mapping techniques were considered in terms of application to field work. (Coad, J., et al., 2007) Art-based techniques, says Coad, give children and young people the opportunity to articulate their feelings through their own visual representations, including those with writing and/or language difficulties, one major challenge is understanding what the art-work means to them (Coad, J. et al., 2007).
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