Using Comics to Communicate About Health: An Introduction to the Symposium on Visual Narratives and Graphic Medicine

Gendered bodies: A graphic medicine commentary

This final commentary, in comic format, frames this special issue using Graphic Medicine methodologies to explore broader themes and meanings related to the scientific study of gender and health. Comics can be seen as a way to introduce complex human narratives and as an exploratory tool to ask broader social-contextual and ethical questions about health and medicine. This piece is also constructed through the lens of queer scholarship, which, together with the comics format, provides opportunities to build more embodied, complicated narratives about gender, sexuality and health. Most importantly, comics are used as a modality to tell compelling narratives about how individuals, rather than populations, may be impacted by biomedical conceptualizations of gender and health. The commentary includes a series of graphic narratives containing hypothetical stories and cases: stories of how individuals may be harmed within healthcare systems by rigid framings of gender, sex and sexuality, and stories about how gender socialization may impact health in subtle ways. These narratives furthermore examine the inextricable link between gender and power, illustrating how overt and covert manifestations of power may shape a person's health over the life course. Finally, the piece explores how expansive views of gender may contribute to positive health care experiences. The intention of this piece is to nudge scientific researchers and clinicians alike to approach the topic of gender, sexuality and health with nuance and curiosity.

Harm reduction stories: leveraging graphic medicine to engage veterans in substance use services within the VA

BACKGROUND

Harm reduction strategies can decrease morbidity and mortality associated with substance use. Various barriers limit conversation around substance use between clinicians and patients. Graphic medicine techniques can inform and encourage patient-centered conversations about substance use. We describe the co-development of a harm reduction-focused graphic medicine comic that depicts the infectious risks associated with injection drug use and patient-centered approaches to providing education about potential risk mitigation strategies.

METHODS

We formed a co-design group of veterans with lived experience with substance use, physicians, health services researchers, and community-based harm reduction leaders. Over the course of ten sessions, the co-design team developed a storyline and key messages, reviewed draft content and worked with a graphic designer to develop a comic incorporating the veterans' input. During each session, co-design leads presented drafts of the comic and invited feedback from the group. The comic was edited and adapted via this iterative process.

RESULTS

The comic depicts a fictionalized clinical vignette in which a patient develops an injection-related abscess and presents to their primary care provider. The dialogue highlights key healthcare principles, including patient autonomy and agency, and highlights strategies for safer use, rather than emphasizing abstinence. Feedback from co-design group participants highlights lessons learned during the development process.

DISCUSSION

Graphic medicine is ideally suited for a patient-centered curriculum about harm reduction. This project is one of several interventions that will be integrated into VA facilities nationally to support incorporation of harm reduction principles into the care of persons who inject drugs.

Seeing the unseen: Comparison study of representation approaches for biochemical processes in education

The representations of biochemical processes must balance visual portrayals with descriptive content to be an effective learning tool. To determine what type of representation is the most suitable for education, we designed five different representations of adenosine triphosphate (ATP) synthesis and examined how they are perceived. Our representations consisted of an overview of the process in a detailed and abstract illustrative format, continuous video formats with and without narration, and a combined illustrative overview with dynamic components. The five representations were evaluated by non-experts who were randomly assigned one of them and experts who viewed and compared all five representations. Subsequently, we conducted a focus group on the outcomes of these evaluations, which gave insight into possible explanations of our results, where the non-experts preferred the detailed static representation and found the narrated video least helpful, in contradiction to the experts who favored the narrated video the most.

'Fight the parasite': raising awareness of cystic echinococcosis in primary school children in endemic countries

BACKGROUND

Cystic echinococcosis (CE) is a widespread zoonosis and a significant economic concern and cause of morbidity in humans. A scarcity of education on the sources of CE infection and containment measures is considered to be a key factor responsible for persistent transmission within communities. Recently, edutainment approaches have captured the attention of health education (HE) professionals due to the benefits of integrating cognitive and emotional learning processes.

METHODS

A study was carried out in Sardinia, Italy, between 2020 and 2022, amid the SARS-Covid-19 pandemic. The project, designed to involve primary school children (via remote or face-to-face learning depending on the evolving Covid-19 containment measures) consisted of four distinct phases: (i) creation of material for school children and teachers focused on cystic echinococcosis; (ii) pre-intervention evaluation of CE knowledge (i.e. True False Don't Know [TFD] pre-intervention questionnaire based on CE-related knowledge and practices); (iii) edutainment activity (e.g. interactive lessons enhanced by the comic booklet and the "Fight the parasite" cartoon video, hands-on educational activities and drawing activities on CE); and (iv) post-intervention evaluation of CE knowledge (via TFD post-intervention questionnaire [same questionnaire as used for the pre-intervention assessment] on CE-related knowledge and practices) and on-site edutainment tour in primary schools taking part to the project.

RESULTS

The percentage of correct answers increased from 65% for the questionnaire administered pre-intervention to 87.9% for the same questionnaire administered post-intervention (χ² = 648.12, df = 1, P < 0.0001), while the percentage of uncertain answers (i.e. 'I don't know') decreased from 23% pre-intervention to 5% post-intervention (χ² = 603.44, df = 1, P < 0.0001). These differences indicate a significantly enhanced understanding of CE among participating school children after the intervention.

CONCLUSIONS

The results of the present survey indicate that the use of digital educational tools, the use of video animations as a model for science communication, as well as other participatory teaching methods, enabled children to retain key knowledge of the routes of CE transmission and ways to prevent it.

A healthy liver will always deliver: development of a NAFLD awareness comic

Comics can be an effective tool to communicate health information and appeal to behavior change. The aim of this project, undertaken by a multidisciplinary team, was to develop a comic to raise awareness about non-alcoholic fatty liver disease (NAFLD) and promote healthy lifestyles regarding dietary practices and regular physical activity patterns. We focused on the ability of comics in portraying abstract concepts to articulate NAFLD biomedical knowledge and use it as an encouragement/empowerment strategy towards disease-related beliefs, attitudes, intentions and behaviors. Formative research by means of a NAFLD awareness study with T2DM patients informed the selection of biomedical content and the design of characters and storylines on which the former was embedded. Mindful of graphic narrative and storytelling as a valuable tool in the domains of health promotion, disease prevention and therapeutic adherence, this work discusses the decisions that were taken for the materialization of the comic ‘A healthy liver will always deliver!’.

The Increase of Knowledge, Attitude, and Practice of Husbands toward the Prenatal Care of their Wives Using the Illustrations Having the Local Cultural Nuance

BACKGROUND: The role of husbands in maternal health during pregnancy is crucial and is related to the high maternal mortality rate in Indonesia. In spite of that, the effort to involve husbands in the maternal health program is still low. AIM: This paper aims to explain the results of the effort to produce learning assisting tools in a form of an illustration having local cultural nuance that can be used to do intervention of health education to increase the participation of husbands in maternal health. METHODS: The research was conducted in Silaen Village, Silaen District in Toba Regency, North Sumatera Province. To make the teaching materials, interviews and focus group discussions were conducted for the village community figures, the village midwives, the pregnant women, and their husbands. After illustrations were made, the trial was conducted to 10 pairs of husbands and pregnant wives. RESULTS: The illustrations made accommodating the role of husbands in maternal health can increase the knowledge, attitude, and practice (KAP) of husbands, including the KAP of their wives. The biggest increase happening in the attitude component (p < 0.05). CONCLUSION: The educational method using an illustration adopting local culture is important to become one of the education teaching alternatives in the effort to improve husband’s KAP.

The use of comics to promote health awareness: A template using nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) constitutes a major threat to public health systems worldwide on account of its widespread prevalence and increasing incidence. More effective tools to raise awareness and increase health communication are therefore needed. Comics may constitute an effective language for this purpose, given the permanence, adaptability and ability of this form of communication to convey complex information, using both visual components and the creation of narrative involvement, thus promoting both awareness and health-conscious behaviours. Importantly, this process requires careful preparation in terms of selecting both the key biomedical concepts to be conveyed, as well as a graphical style and appropriate characters and a narrative arc with which a target audience can identify with. Here we provide a brief introduction to the use of comics in health communication and propose a possible roadmap for the development of comic-based tools for diverse conditions, using the context of NAFLD.

Intervention Effects in Using an Application Compared with a Module with Pictures on Knowledge, Attitude, and Practice of the Pregnant Women in North Sumatra, Indonesia

BACKGROUND: Pregnancy period is a crucial period for the maternal and infant health. Unfortunately, there are still many pregnant women having low knowledge, attitude, and practice (KAP). Meanwhile, the advanced technology and the occurrence of pandemic should have created change toward the method to provide education. AIM: This research aims to compare the KAP of the pregnant women provided by an application with those provided with a module with pictures. METHODS: This research was conducted in Deli Serdang Regency, North Sumatera Province. There were two groups of pregnant women, each of which consists of 32 people chosen from the pregnant women registered in two Public Health Centers. One group used the application and the other used the module with pictures. After 3 months, the KAP of those two groups was measured in accordance with the content of the module. RESULTS: Those two groups had the profile of the same age and education, but their occupation was different, where the application users were mostly housewives, while the most of the module users were self-employed. The pregnant women using the application had a higher KAP than the pregnant women using the module with pictures. CONCLUSION: The use of the application and the module with pictures is an important alternative to increase the KAP of the pregnant women.

Developing a health education comic book: the advantages of learning the behaviours of a target audience

The objective of this study was to determine the positive and negative coping mechanisms practiced by parents of paediatric inpatients and outpatients in order to prepare a health educational comic aimed at improving these response mechanisms. Data were collected from parents visiting general paediatric outpatient clinics or hospitalisation units, at a children's hospital in a metropolitan city. Data analysis was based on 258 completed surveys received from 308 (83.77%) respondents. Each parent completed a survey that included the Brief-COPE-Coping Orientation to Problems Experienced questionnaire that encompassed 14 subscales of positive and negative coping mechanisms. Parents used both positive and negative coping mechanisms in outpatient clinics and hospitalisation units. Scores involving negative coping mechanisms were increased and associated with the severity of a child's reason for visiting a children's hospital. The lowest scores were reported by parents whose children were seen at outpatient clinics, whereas the highest scores were reported by parents whose children were treated in critical care units. Learning about parents' coping mechanisms provided key information for preparing an electronic health education comic book (electronically distributed free of charge) and can be used to teach and promote the reinforcement of positive rather than negative coping mechanisms.

Advancing Visual Health Communication Research to Improve Infodemic Response

During public health crises like the ongoing novel coronavirus pandemic, there is a need to amplify and improve critical health communication messages. This need is due to pandemics producing infodemic conditions, meaning the public information environment is oversaturated with information of questionable accuracy and utility. The strategic use of visuals can be leveraged to improve the quality of health communication during public health crises and lessen the unintended effects of infodemic conditions. In this essay, we review previous visual communication theorizing and research that provide insights for effective and efficient use of graphical (e.g., data visualizations) and illustrative (e.g., photos, illustrations, and content features) visuals. We also discuss and advocate for more systematic research on visual misinformation and visual narratives, as there are significant gaps in the literature about how people interpret, act on, and engage with these visual content types. More systematic research about these areas of visual health communication research will improve public communication during future public health crises.

Creation and Initial Validation of a Picture-Based Version of the Limitations of Activity Domain of the SF-36

Those with limited language comprehension or literacy face problems completing written questionnaires evaluating their health or physical status on which treatment plans are based. This brief report describes how a picture-based version of the 10 items in the limitations of activities section of the short form 36 health survey questionnaire (SF-36) was developed iteratively and then piloted. Study participants were 101 community-living volunteers (58 female and 43 male volunteers aged 18-93 yrs) educated to postsecondary level (52), high school grades 10-12 (44), and grade 9 or less (5). They first completed the picture-based SF-36 LoA and described verbally and in writing what they understood each picture to mean and then completed the English text version of the SF-36 limitations of physical activities domain for comparison assessment. Additional feedback suggested where pictures could be altered to increase information capture. Subjects rated their health as 26.7% excellent, 25.7% very good, 29.8% good, 10.9% fair, and 6.9% poor. Analysis showed strong correlation between text-based SF-36 LoA questions and the picture-based visual score-VSF-36 LoA-(intraclass correlation coefficient = 0.98) with question 10 correlating highest (intraclass correlation coefficient = 0.90) and question 2 lowest (intraclass correlation coefficient = 0.82). The VSF-36 LoA is the first picture-based version of the SF-36; good correlation with the text-based version and global need warrants further development to aid those with limited literacy or language comprehension.

Using a fotonovela to battle crystal meth in South Africa

This study evaluated the effects of a health-related fotonovela about crystal meth (S-methamphetamine hydrochloride) among "Colored" people (an ethnic label for people of mixed race) in the Western Cape province of South Africa. Crystal meth use is most common among Colored people in this province and it is considered a major social problem. The fotonovela was compared to a no-message control group and a traditional brochure in a randomized controlled trial (N = 303). The fotonovela outperformed the control condition for knowledge level and it outperformed the traditional brochure on intention toward starting conversations about crystal meth. Especially readers with relatively low levels of education clearly preferred the fotonovela over the traditional brochure.

Comics as a Medium for Parent Health Education: Improving Understanding of Normal 9-Month-Old Developmental Milestones

Multimodal literacy, a product of modern technology, can aid in the recall of simple-to-complex information for both children and adults. Health education information presented using educational comics takes advantage of multimodal formats and designs based on theoretical models of learning. In this study, we utilized a quasi-experimental design with both pre- and post-intervention testing. The parents of every other patient that attended the well-child appointments of their child aged <9 months were invited to participate in this study. Participants were drawn from three pediatric clinics, with a total of 280 parents included in the study. Each parent completed a pre-intervention test consisting of an eight-item questionnaire regarding the developmental milestones of a 9-month-old child. After responding to the questionnaire, the parents received a comic about a 9-month-old child reaching age-appropriate developmental milestones. Four to six weeks after the comics were provided to the parents, they responded to the same questionnaire by phone, which consisted of the same eight questions plus an additional question regarding possible additional uses of the comic. Parents significantly increased their recall of information of developmental milestones when the pre- and post-intervention test results were compared, with a significance of p < 0.001 at a 95% confidence level. Additional uses of the comic reported by parents included calling their pediatrician with doubts about their own child's appropriate achievement of milestones, and lending the comics to relatives or friends. The educational comic appeared to assist parents in making meaningful connections between the simplified pictures and the developmental milestones of their child. Comics may provide an alternative for parental education using this multimodal format to explain simple-to-complex issues.

Difficult Doctors, Difficult Patients: Building Empathy

Effective doctor-patient communication facilitates the therapeutic relationship, promotes patient physical and mental health, and improves physician satisfaction. Methods of teaching effective communication use a range of techniques, typically combining didactic instruction with simulated communication encounters and reflective discussion. Rarely are patients and physicians exposed to these instructions as colearners. The evidence for the utility of graphic stories, comics, and cartoons to improve patient comprehension and self-regulation is small but encouraging. The authors describe the use of graphic medicine as a teaching tool for engendering empathy from both the physician and the patient for the other during a shared clinical encounter. This use of educational comics in a colearning experience represents a new use of the medium as a teaching tool.