Pictograms in a low literate population

Dowse, Ros, and Martina S. Ehlers. “The Evaluation of Pharmaceutical Pictograms in a Low-Literate South African Population”. Patient Education and Counseling 45, no. 2 (2001): 87-99.

This research study compared how locally developed pharmeceutical pictograms compared to pictograms that were developed without end user input. Pictograms created without participatory design were paired with a locally developed pictogram that had the same meaning. This study took place in South Africa among a group of 46 people who had attended school for a maximum of 7 years.

Participants were first asked to provide their interpretation of each pictogram. Three weeks later, they were polled again. Participants also stated their preference for the localized or the generic pictograms. At the end of the study 20 of the 23 locally developed pictograms rated at greater than 85% comprehension, compared to just 11 of 23 generic pictograms.

This study shows that there is value in creating pictograms with end user input. Each culture has a unique way of looking at the world and interpreting information. These unique viewpoints affect how we perceive all kinds of things, even something as simple as a line drawing of a body part. While the sample size of this study is small, it would be a great starting point for additional research. Other cultures could be studied--even regional differences could be studied.

Pictograms and Participatory Design

Hyeoneui, Kim, Carlos Nakamura, and Qing Zeng-Treitler. “Assessment of Pictographs
Developed Through a Participatory Design Process Using an Online Survey Tool. “Journal of Medical Internet Research 11, no. 1 (2009). http://www.jmir.org/2009/1/e5/(accessed March 21, 2011).

This journal article outlines a study done comparing the efficacy of pictograms developed using participatory design to pictograms developed without end user input. Participants assessed both types of pictograms using an online assessment tool, where they picked a phrase they felt most accurately represented the meaning of the pictogram. Participants were randomly selected from a group of the researchers' colleagues and acquaintances. The researchers analyzed the responses and determined that the pictograms developed using participatory design were more effective than those developed without end user input.

One drawback of this study is that the researchers used a convenience sample of acquaintances and colleagues. As the researchers work in the healthcare system (one of them works at a department within Harvard Medical School), their colleagues and acquaintances are likely to be better educated and more technically savvy than the average American. While the researchers discussed the problem of low health literacy levels in America, the sampling strategy they chose couldn't have been very representative.

Another drawback I noticed was that the pictograms created using participatory design (PD) weren't expressing the same concepts as the other pictograms being analyzed. The PD pictograms expressed home care or medication compliance concepts, like "come to the emergency room if you can't eat food", "take this drug on an empty stomach", or "don't take tub showers". The other pictograms were really designed to help patients with wayfinding within hospitals, helping them find departments like like "Social Service", "Outpatient Care, and "Diabetes Education". The researchers did recognize this limitation, but stated that they were really trying to analyze pictograph recognition rather then a direct comparison. Still, I think this study would have been more useful if they employed a direct comparison method.

Using visuals to make health materials more clear

Osborne, Helen. “In Other Words…Using Visuals and Other Creative Tools to Make Health Messages Clear.” On Call Magazine (May 8, 2008). http://www.healthliteracy.com/article.asp?PageID=7409 (accessed March 21, 2011).

In this artice from the now defunct On-Call magazine, health literacy expert Helen Osborne describes real-life examples of how different cultures perceive visuals differently. One example she cites involves a Peace Corps volunteer who used a projector to teach residents in a rural village in Columbia about the dangers of malaria. He showed several enlarged images of mosquitoes to the villagers. At the end of his presentation, the villagers told the volunteer they didn't have a problem with mosquitoes because the ones they had were not as big as the ones shown using the projector.

Osborne also cites practical methods that writers and educators can use to make their visuals more effective to the end user. Osborne suggests teaching end users what the visuals mean. Simply creating a visual and giving it to a user can lead to misinterpretation, which can have harmful results in the field of healthcare. Osborns also recommends using line drawings rather than photographs, as photographs often contain too much information that can overwhelm and distract the audience. Combining visuals with another method, such as songs, radio announcements, and contests help users better understand and apply what they have learned. These methods also reach users outside of the target audience, which can help reinforce the concept being taught (children hearing a health message on the radio may ask their parents for more information, and the parents may teach the child about the concept).

Helen Osborne is a nationally well-known health literacy expert, and has written 5 books regarding the importance of health literacy, and how best to communicate with patients. She used to write a column for On-Call magazine, published by the Boston Globe. Her personal website is full of articles and poscasts designed for health professionals and writers. This article is useful to my research as it cites specific examples of how people with low literacy, or people from different cultures understand visuals differently. While it doesn't specifically mention participatory design, she describes methods for creating visuals that involve the end user.

Developing Health and Family Planning Print Materials for Low-Literate Audiences: A Guide

Zimmerman, Margot, Nancy Newton, Lena Frumin, and Scott Wittet. Developing Health and Family Planning Print Materials for Low-Literate Audiences: A Guide. (Seattle, WA: Program for Appropriate Technology in Health [PATH], 1996).

This manual is specifically geared towards organizations looking to create their own print materials. The manual outlines the techniques used by an organization called Program for Appropriate Technology in Health (PATH) to communicate to illiterate and low-literate people. The manual states that PATH’s techniques have been used in over 40 countries; however, they do not provide data on the efficacy of their own material. This manual would be most useful to organizations who are developing health education materials for specific populations. I had hoped that this manual would contain more specifics on how different cultures perceive images. However, this manual outlines ways define the target audience, methods for gathering data from target audiences (including types of research), how to tailor information to specific stages of behavior adoption, and design considerations. While the content appears credible, and PATH is an established nonprofit organization, this source doesn’t specific data that could be included in my research project. It isn’t clear if the suggestions and tips contained in this manual have been peer-reviewed, subject to research, or follow an established standard. However, the manual does provide a 20-item bibliography that may be provide additional resources for my research topic. While the manual is not an appropriate source for a research paper, the bibliography may prove invaluable when searching for more information on the topic of developing culturally relevant visuals.

Visual Literacy in Non-Western Cultures

Miltenburg, Anne. “Visual Literacy in Non-Western Cultures,” in Morf 3 (2005). http://anne miltenburg.com/morf/ (accessed February 10, 2011).

This article was originally published in a Dutch-language design magazine. While it is not a traditional journal article, it describes issues that affect how non-Western cultures interpret visuals developed by Western cultures. The author notes that non-Western cultures often have higher illiteracy rates than Western cultures, and are often have limited exposure to visuals developed by Western cultures. The author cites research on visual literacy by scholar and art-director Andreas Fuglesang. Fuglesang found that people who are visually illiterate have trouble reading two-dimensional images like photos and illustrations. This translates into difficulty perceiving differences in shape, size, height, and perspective. As many non-Western cultures convey information through oral means, people in these cultures may also be less familiar in the use of visuals to convey information. In this article, Miltenburg outlines areas where non-Western cultures have trouble interpreting visuals, specifically regarding photos, depth perception, portraying movement, object identification, cropped images, and illustrations. Miltenburg also discusses the use of color, as the significance of various colors can vary from culture to culture, impacting the interpretation of the visual. Miltenburg cites Fuglesang’s research throughout her article, and provides a citation to his book Applied Communication in Development Countries, Ideas and Observations (as this article was originally written in Dutch, the English title may be slightly different). The primary drawback to this source is that it relies on the author’s interpretation of Fuglesang’s research—there isn’t any new research described in this article. Also, Fuglesang’s book is out of print, so it would be hard to analyze his research directly. I also noted that Miltenburg describes Fuglesang as Norwegian in this article, and as Swedish in a different article. This discrepancy does shed some doubt as to the credibility of this piece.

A Participatory Approach to Communication for Developing Countries

Andrews, Deborah C. “A Participatory Approach to Communication for Developing Countries,” in Managing Global Communication in Science and Technology, ed. Peter J. Hager and H.J. Scheiber (New York: John Wiley & Sons, 2000), 67-83.

This article, which appears as a chapter within the book Managing Global Communication in Science and Technology, outlines the complexities involved when developing solutions to problems in developing countries. The author advises that organizations can only develop effective solutions to problems by listening to the voice of the local people. The article advises that soliciting feedback from local people empowers them and makes them more fully vested in the outcome of the project. The author cites several case studies, and also reviews how focus group discussions (FGDs)can be used to facilitate feedback. The article specifically focuses on how one non-governmental organization (NGO) called Program for Appropriate Technology in Health (PATH) uses FGDs to design health information materials. Initially, PATH determines the level of audience (policy/decision makers, program managers, clinicians, fieldworkers, or clients), profiles their needs, then develops their message. The message is then tested on audience to see if it meets their needs. The article provides 6 different sets of visuals that were created and then adapted based on this feedback. One specific image was designed to show Kenyans that pregnant women should carry lighter loads than women who aren’t pregnant. The initial image depicted a woman carrying a heavy load with an “X” superimposed over the women’s figure. Low-literate audiences in Kenya initially did not understand the meaning of the “X”, so the image was redesigned to show a visibly pregnant woman carrying a smaller load than a non-pregnant woman. I feel that this article and its accompanying bibliography could prove helpful for my paper, as it outlines specific research done with the assistance and input of the local people.