Review
The role of pictures in improving health communication: A review of research on attention, comprehension, recall, and adherence

https://doi.org/10.1016/j.pec.2005.05.004Get rights and content

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.

Section snippets

Methodology

For each possible use of pictures (to facilitate attention, comprehension, recall and adherence), we reviewed studies that compare response to just text (written or spoken) with response to text plus pictures representing information in the text. We also reviewed studies comparing different types of pictures and studies comparing responses to pictures by different populations. Data bases of research publications in education, (ERIC) medicine (PUBMED), psychology (PsycINFO), and marketing

Problem statement

Not all health communications are read by people who could benefit. Racks of informational brochures in doctors’ offices are often ignored and, even when brochures are given to patients by health professionals, not all are read. Even spoken instructions by health professionals are not always attended to by patients or families because they are stressed, distracted, or confused. One contribution of pictures to health education is to attract the attention of patients and families and to stimulate

Problem statement

Patients sometimes have difficulty understanding health care information. Studies by Ley [7] and others have shown that health information is often unfamiliar to patients and contains complex concepts and words. This is, in part, caused by the tendency of health professionals to use the same technical terminology and complex sentence structures in communicating with patients that they use in communicating with their professional peers. Another reason is the inherent complexity and uncertainties

Problem statement

Once a health message is understood, people must remember the message in order to use it. Health professionals frequently give important information by speaking, but usually only once. Studies show that patients remember from 29 to 72% of what doctors tell them, and the more information the doctor presented, the lower the recall rate [7]. And even with written instructions, most people read them only once and then rely on their memories when taking health actions. Even if they do refer back to

Problem statement

Behavior or “adherence” is the final and most important outcome for health education. It is not enough to notice, understand, and remember a message. The person must carry out the recommended actions. Adherence involves two steps: accepting the message as something the person should act on and then actually carrying out the recommended actions. We consider these steps (intending and acting) separately.

Do pictures affect health intentions and behavior?

Three studies have investigated whether pictures affect the intention to carry out recommended

Discussion

The research cited in this paper shows that adding pictures to written and spoken language can increase patient attention, comprehension, recall and adherence. In many cases these benefits were large. The effectiveness of health communications can be significantly increased by including pictures in the design of new health education materials. Furthermore, many existing health education materials could be improved by the judicious addition of pictures. More research is needed, but the potential

Practice implications: a summary of recommendations for using pictures in health education

The following recommendations combine research findings discussed above with the authors’ experiences in working extensively with pictures in health education—both in creating and evaluating printed materials. We also draw on recommendations by Dowse and Ehlers [45] and by Rohret and Ferguson [46] in their earlier reviews of the role of pictures in health education. We offer seven recommendations.

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